Repeat Endoscopy Research Articles

Risk of Bleeding After Percutaneous Endoscopic Gastrostomy in Patients Using Antithrombotic Drugs.

The rate of using antithrombotic (AT) drugs is frequently high in patients who require percutaneous endoscopic gastrostomy (PEG). The aim of this study was to determine whether the risk of bleeding after PEG increases in patients whose AT drugs were discontinued according to the European Society Gastrointestinal Endoscopy guidelines (warfarin for 5d, low molecular weight heparin for 24h, DOAC for 3d, and clopidogrel for 7d). Data from 243 patients, who underwent PEG tube placement and received AT drugs and 206 patients who did not between 2018 and 2021 in our hospital, were evaluated retrospectively. Bleeding was defined as requiring blood transfusion, hematemesis and/or melena, decreased hemoglobin, or bleeding from PEG. A total of 243 (54.1%) patients (121 (49.7%), women, mean age (75.7y) who underwent PEG and received AT drugs, and 206 (45.9%) patients who did not (92 (44.6%), women, mean age (63.15y). The medications and bleeding rates of the patients are given in Table 1. The rate of bleeding in patients using AT medication was significantly higher than that in patients not using medication (Table 2) ( P = 0.007). When the AT drugs were compared among themselves, the bleeding risk did not differ. Bleeding was detected in 10 patients with bleeding from the PEG tube in 4 with melena. Bleeding detected in 14 patients was controlled with adrenaline injections. None of the patients required transfusion or repeat endoscopies. No bleeding-related deaths were reported. Even if patients receiving AT drugs are treated as recommended by international guidelines, it should be kept in mind that bleeding may occur after PEG, and the patients should be followed accordingly.

A single-center prospective study on pain alleviation during peroral upper endoscopy with an ultrathin endoscope

BackgroundThe efficacy of transnasal endoscopy using an ultrathin endoscope has been reported in several studies. However, few studies regarding peroral endoscopy with ultrathin endoscopes with high resolution have been reported. This study investigates the pain alleviation of peroral endoscopy with an ultrathin endoscope.MethodsPatients with a history of peroral endoscopy using a conventional, normal-diameter scope with no sedation who underwent peroral esophagogastroduodenoscopy (EGD) using a thin scope between April-July 2022 were included in this study. After the procedure, the patients completed a questionnaire evaluating pain during the examination and willingness to repeat the procedure. The physicians were surveyed regarding their level of satisfaction. The primary endpoint was patient satisfaction, which corresponded to the rate of patients who rated the thin endoscope as more comfortable or somewhat more comfortable than the previously-used, conventional endoscope.ResultsOne hundred and forty-five patients were included in the analyses. Patient satisfaction was achieved in 86.2% (125/145) of patients. The median visual analog scale pain score was 3 (0–7) points in this study, which is significantly lower than the pain score after the previous endoscopy (5 (0–10) points; p < 0.001). In addition, 96% (24/25) of patients who underwent EGD by an expert and 95.8% (115/120) who underwent EGD by a non-expert were willing to repeat endoscopy using the thin scope (p = 0.69).ConclusionPeroral endoscopy using a thin scope reduces patient pain regardless of the endoscopist’s experience.

A dietitian-led coeliac service helps to identify and reduce involuntary gluten ingestion with subsequent reduction in the frequency of repeat endoscopies.

Dietitian-led coeliac clinics have the potential to be a cost-effective way of monitoring patients living with coeliac disease (CD). The aim of this service evaluation was to explore the impact of a dietitian-led coeliac clinic on gluten-free diet (GFD) adherence and the frequency of endoscopies with repeat duodenal biopsies. Adults with biopsy-proven CD were transferred to a new dietitian-led coeliac clinic where data were collected from medical records and analysed using SPSS. GFD adherence was assessed by a specialist dietitian, specialist nurse, consultant gastroenterologists and a validated GFD adherence questionnaire. Repeat duodenal biopsy findings were compared with the most recent dietitian GFD adherence assessment. Project and ethics approval was granted by the hospital trust and affiliated university. Data from 170 patients (White: 51%, South Asian: 45%) are presented, with most being 35-64 years old (61%). Specialist dietitian assessments identified 67 (39%) of patients were adhering to the GFD, whereas prior gastroenterologist or coeliac nurse assessments identified 122 (72%) (p < 0.001) and the validated GFD adherence questionnaire identified 97 (57%) (p < 0.001). Dietitian assessments identified involuntary gluten consumption in 39/104 (38%) of those who self-reported GFD adherence, consequently avoiding the need for nine endoscopies with repeat duodenal biopsies once patients had received dietary education from the dietitian. On follow-up, within the dietitian-led coeliac clinic, significantly fewer patients consumed gluten involuntarily (14%, p < 0.001). In addition, a reduction in voluntary gluten consumption was observed from three to five to one to two times per month (p < 0.001) in 66 patients. The dietitian-led coeliac clinic helped to identify involuntary gluten ingestion, avoid repeat endoscopies with duodenal biopsies and was associated with significantly improved GFD adherence.

Susceptibility of nucleotide-binding oligomerization domain 2 mutations to Whipple's disease.

Whipple's disease (WD) results from infection of the bacteria Tropheryma whipplei (TW). This disease is characterized by macrophage infiltration of intestinal mucosa and primarily affects Caucasian males. Genetic studies of host susceptibility are scarce. Nucleotide-binding oligomerization domain containing protein 2 (NOD2) is an innate immune sensor, resides mainly in monocytes/macrophages and contributes to defence against infection and inflammatory regulation. NOD2 mutations are associated with autoinflammatory diseases. We report the association of NOD2 mutations with TW and WD for the first time. A multicentre, retrospective study of three patients with WD was conducted. Patients received extensive multidisciplinary evaluations and were cared for by the authors. NOD2 and its association with infection and inflammation were schematically represented. All patients were Caucasian men and presented with years of autoinflammatory phenotypes, including recurrent fever, rash, inflammatory arthritis, gastrointestinal symptoms and elevated inflammatory markers. All patients underwent molecular testing using a gene panel for periodic fever syndromes and were identified to carry NOD2 mutations associated with NOD2-associated autoinflammatory disease. Despite initially negative gastrointestinal evaluations, repeat endoscopy with duodenal tissue biopsy ultimately confirmed WD. After initial ceftriaxone and maintenance with doxycycline and/or HCQ, symptoms were largely controlled, though mild relapses occurred in follow-up. Both NOD2 and TW/WD are intensively involved in monocytes/macrophages. WD is regarded as a macrophage disease. NOD2 leucin-rich repeat-associated mutations in monocytes/macrophages cause functional impairment of these cells and consequently may make the host susceptible for TW infection and WD, especially in the setting of immunosuppression.

Safety and efficacy of direct percutaneous endoscopic jejunostomy placement in patients with previous upper gastrointestinal resection: A retrospective cohort study.

Percutaneous jejunal enteral access can be obtained with percutaneous endoscopic gastric jejunostomy (PEGJ) and direct percutaneous endoscopic jejunostomy (DPEJ) tubes. PEGJ may not be feasible in patients with previous gastric resection (PGR) and DPEJ may be the only option. Our aim is to determine if DPEJ tubes can be placed successfully in patients with history of gastrointestinal (GI) surgery and if success rates are comparable to DPEJ or PEGJ in those without prior GI surgery. We reviewed all tube placements performed from 2010 to present. Procedures were performed using a pediatric colonoscope. Previous upper GI surgery was defined as PGR or esophagectomy with gastric pull-up. Adverse events (AEs) were graded perAmerican Society for Gastrointestinal Endoscopy criteria. Mild events included unplanned medical consultation or hospitalization <3 days, and moderate events included repeat endoscopy without surgical intervention. Successful placement rates were high regardless of GI surgical history. Patients receiving a DPEJ with a history of GI surgery were significantly less likely to experience an AE compared with those receiving DPEJ with no history and compared with PEGJ patients with or without a history. DPEJ placement in patients with previous upper GI surgery has very high success rate. It is associated with lower AE rates than patients receiving DPEJ without previous gastric surgery, or PEGJ regardless of previous gastric surgery. Patients with a history of upper GI surgery requiring enteral access may benefit from DPEJ over PEGJ placement considering its very high success rate and lower incidence of AEs.

Utilizing Endoscopy for the Diagnosis of Acute Upper Gastrointestinal Bleeding.

Background Acute upper gastrointestinal bleeding (UGIB) is a medical emergency requiring immediate diagnosis. While endoscopy is a commonly employed procedure in the evaluation of UGIB, its timing, outcomes, and the range of identified causes vary widely across different medical settings and regions. Therefore, the purpose of this study was to use endoscopy to investigate the cause of UGIB. Methodology A cross-sectional study was conducted at the Department of Gastroenterology, Mayo Hospital, Lahore, over a period of one year, from July 1st, 2021 to June 28th, 2022. The study enrolled all patients who were 18 years of age or older and exhibited symptoms of UGIB, including hematemesis and/or melena, within 48 hours of onset. An upper gastrointestinal endoscopy procedure was conducted in order to identify the underlying cause of UGIBand to apply appropriate therapeutic interventions. In patients where the endoscopic examination revealed bleeding ulcers, a specimen for biopsy was excised to test for Helicobacter pylori. Similarly, in cases where a malignancy was suspected during the endoscopy, a biopsy was performed for confirmatory diagnosis. A pre-designed proforma was utilized to collect data including the demographic variables such as age, gender, ethnicity, family history; clinical variables such as clinical presentation, comorbidities, medical history, medication use, vital signs, biochemical evaluation, and imaging results; endoscopic findings such as endoscopic location and severity of bleeding, endoscopic diagnosis, and the use of endoscopic interventions. Information relevant to the treatment and outcomes was also observed. Under outcomes, the rates of re-bleeding, need for repeat endoscopy, length of hospital stay, and mortality were recorded. Results The study reports that the mean age of the participants was 54.72 years with a standard deviation of 12.5 years. The mean hemoglobin level at the presentation was 7.98 ± 2.88 mg/dl. Out of the 309 patients, 215 (69.58%) were male, 202 (65.37%) presented with hematemesis, 97 (31.39%) presented with melena, and 10 patients had a mixed presentation. A total of 154 (49.84%) patients had portal hypertension. Out of these, 128 (83.12%) had esophageal varices and 21 (13.64%) had gastric varices. Five patients suffered from portal hypertensive gastropathy. In 114 (36.89%) patients, the cause of bleeding was ulcerative disease and out of these, duodenal ulcers were found in 49 (42.98%) while gastric ulcers were found in 22 (19.30%) patients. In total malignant lesions were detected in 20 (6.47%) cases. Conclusion The researchindicates that hematemesis was the predominant initial symptom observed in individuals experiencing UGIB. The predominant etiology of the hemorrhage was identified as esophageal and gastric varices through endoscopic assessment. The study highlights the importance of early endoscopic evaluation in patients with UGIB as it can help identify the cause and guide appropriate management. This emphasizes the need for healthcare providers to be vigilant in identifying and managing patients with UGIB promptly to improve outcomes. Further research is needed to explore effective strategies for early detection and management of UGIB.

Characterization and Short-Term Outcome of Potential Celiac Disease in Children.

Background and Objectives: Potential Celiac Disease (PCD) is defined by positive celiac serology without villous atrophy. We aimed to describe the short-term outcome of pediatric PCD while consuming a gluten-containing diet (GCD). Materials and Methods: Retrospective analysis of pediatric PCD patients continuing GCD, between December 2018-January 2022. Baseline demographics, celiac serology and duodenal biopsy results were reviewed. Follow-up data included repeated serology and biopsy results when performed. Minimum follow-up was 12 months unless celiac disease (CeD) was diagnosed earlier. Results: PCD was diagnosed in 90 children (71% females) with a mean age of 7.2 (range 1.8-16.5) years. Baseline anti-tissue transglutaminase (TTG) levels were above 10 times the upper limit of normal (ULN) in 17/90 (18.9%), 3-10 × ULN in 56/90 (62.2%) and 1-3 × ULN in 17/90 (18.9%). During follow-up, the mean time was 17.6 (range 5-35) months, TTG normalized in 34/90 (37.8%), was stable in 48/90 (53.3%), and increased or remained >10 × ULN in 8/90 (8.9%). In 20/90 (22.2%) patients, a repeat endoscopy was performed, leading to CeD diagnosis in 12/20 (60%). Thus, at the end of follow-up, CeD was diagnosed in 12/90 (13.3%). In patients with TTG >10 × ULN at diagnosis, TTG normalized in 5/17, decreased to 3-10 × ULN in 8/17, and remained above 10 × ULN in 4/17. Conclusions: During the short-term follow-up of pediatric PCD patients, less than 15% progressed to CeD. A third had normalized TTG levels, including children with TTG >10 × ULN, indicating the need for periodic serological and histological follow-up among PCD patients.

Endoscopic treatment of acute oropharyngeal stick injuries in dogs: 46 cases (2010-2020).

To review long-term outcomes of dogs with acute oropharyngeal stick injuries managed with rigid endoscopy at a UK referral centre. Retrospective analysis and follow-up with referring veterinary surgeons and owners of patients treated between 2010 and 2020. A medical record search was performed and data regarding signalment, clinical presentation, treatment and long-term outcomes were recorded. Sixty-six dogs with acute oropharyngeal stick injury were identified and 46 (70.0%) of these had endoscopy of the wound. The dogs were of various breeds, ages (median=3 years; range 0.6 to 11 years) and weights (median=20.4 kg; range 7.7 to 38.4 kg) and 58.7% of patients were male. The median time from injury to referral was 1 day (range 2 hours to 7 days). Patients were anaesthetised, and injury tracts were explored using 0° and 30° forward-oblique, 2.7 mm diameter, 18 cm length rigid endoscopes with a corresponding 14.5 French sheath using saline infusion via gravity. All foreign material that could be grasped was removed using forceps. Tracts were flushed with saline and reinspected to confirm removal of all visible foreign material. Out of 40 dogs with long-term follow-up, 38 (95.0%) had no major long-term complications. The remaining two dogs developed cervical abscessation after endoscopy, one of which resolved after repeat endoscopy and the other resolved after open surgery. Long-term follow-up of dogs with acute oropharyngeal stick injury managed with rigid endoscopy showed an excellent outcome in 95.0% of cases.

Secondary Prevention of Esophageal Variceal Bleeding Is Often Imperfect: A National, Population-Based Cohort Study of 3592 Patients

Secondary prevention of esophageal variceal bleeding is important to improve prognosis, but uptake of guidelines is unknown in a real-world setting. Here, we determined the proportion of patients receiving appropriate nonselective beta-blocker treatment and repeat upper endoscopy after a first episode of esophageal variceal bleeding within a reasonable time frame. Population-based registers were used to identify all patients with a first episode of esophageal variceal bleeding in Sweden from 2006 to 2020. Crosslinkage between registers was performed to receive information on the cumulative incidence of patients with a dispensation of nonselective beta-blockers and repeat upper endoscopy within 120 days from baseline. Overall mortality was investigated using Cox regression. In total, 3592 patients were identified, with a median age of 63 (interquartile range, 54-71) years. The cumulative incidence of a dispensation of nonselective beta-blockers and a repeat endoscopy within 120 days was 33%. A total of 77% received either of these treatments. Overall mortality was high, with 65% of patients dying after esophageal variceal bleeding during the full follow-up period (median 1.7 years). We observed an improved overall mortality during the later years of the study period (adjusted hazard ratio for the 2016-2020 period compared with the 2006-2010 period, 0.80; 95% confidence interval, 0.71-0.89). Patients with receipt of nonselective beta-blockers and repeat upper endoscopy had better overall survival compared with those without (adjusted hazard ratio, 0.80; 95% confidence interval, 0.72-0.90). Secondary prevention of esophageal variceal bleeding has not been widely undertaken, with many patients not receiving guideline-supported interventions within a reasonable time frame. This highlights a need to raise awareness on appropriate prevention strategies to clinicians and patients.

A new protective gel to facilitate ulcer healing in artificial ulcers following oesophageal endoscopic submucosal dissection: a multicentre, randomized trial

There are significant risks of adverse events following oesophageal endoscopic submucosal dissection (ESD), such as stricture, delayed bleeding and perforation. Therefore, it is necessary to protect artificial ulcers and promote the healing process. The current study was performed to investigate the protective role of a novel gel against oesophageal ESD-associated wounds. This was a multicentre, randomized, single-blind, controlled trial that recruited participants who underwent oesophageal ESD in four hospitals in China. Participants were randomly assigned to the control or experimental group in a 1:1 ratio and the gel was used after ESD in the latter. Masking of the study group allocations was only attempted for participants. The participants were instructed to report any adverse events on post-ESD days 1, 14, and 30. Moreover, repeat endoscopy was performed at the 2-week follow-up to confirm wound healing. Among the 92 recruited patients, 81 completed the study. In the experimental group, the healing rates were significantly higher than those in the control group (83.89 ± 9.51% vs. 73.28 ± 17.81%, P = 0.0013). Participants reported no severe adverse events during the follow-up period. In conclusion, this novel gel could safely, effectively, and conveniently accelerate wound healing following oesophageal ESD. Therefore, we recommend applying this gel in daily clinical practice.

Frailty predicts mortality in patients with upper gastrointestinal bleed: a prospective cohort study.

Evidence on the impact of frailty in patients with upper gastrointestinal bleed (UGIB) is limited. This study aims to define the role of frailty as defined by Canadian Study of Health and Aging clinical frailty scale (CSHA-CFS) in predicting mortality in UGIB. A prospective single-center cohort study was conducted over 21months on all consecutive patients with UGIB. Data on demographics, lab parameters, Glasgow Blatchford score, CSHA-CFS, Charlson Comorbidity Index, and AIMS65 score was recorded. The primary outcome was all-cause inpatient mortality. The secondary outcomes were all-cause 30-day mortality, 30-day rebleeding, 30-day readmission, hospital length of stay (LoS), intensive care unit (ICU) admission, need for repeat endoscopy, and need for blood transfusion. The data were evaluated using univariate and multivariate analysis. There were 298 eligible patients, of which 63% were males, median age was 68years, 44% were from non-English-speaking background, and 72% had major comorbidities. The all-cause inpatient and 30-day mortality were 9.4% and 10.7%, respectively. In the multivariate analysis, CHSA-CFS was the independent predictor of all-cause inpatient mortality (OR 1.66; 95% CI 1.13-2.143; P=0.010) and all-cause 30-day mortality (OR 1.83; 95% CI 1.26-2.67; P=0.002). CHSA-CFS was not a significant predictor of 30-day rebleed, 30-day readmission, ICU admission, hospital LoS, or need for blood transfusion. Frailty is an important independent predictor of mortality in patients with UGIB. Frailty assessment can guide clinical decision making and allow targeting of health-care resource (Australia/New Zealand Clinical Trial Registry number: ACTRN12622000821796).

Clinical Characteristics of Peptic Ulcer Disease &amp; its Pharmacological Management in Primary Care

Background: Peptic ulcer diseases (PUD) are common conditions reported in daily clinical practice. Proton pump inhibitors (PPIs) are the most potent pharmacological inhibitors of gastric acid secretion. Aims &amp; objectives: This study aimed to evaluate &amp; understand the clinical presentation and management of PUD with PPIs in general practice. Methods: This prospective study was conducted on 150 diagnosed cases of PUD patients in a single center of private practice in rural areas from February 2022 to August 2022. Patients were enrolled by following inclusion &amp; exclusion criteria with informed written consent. Eight (08) weeks after the completion of treatment by giving PPIs, a repeat endoscopy was done to see the improvement of healing of the ulcer. All data were collated and results were expressed in percentages which are illustrated in different tables &amp; figures. Results: Among 150 endoscopically diagnosed PUD patients major age group was 31-40 years (50%) of both sexes where the male (58.66%) were more predominant. Abdominal pain (82%), heartburn (56.66%), etc were the main clinical symptoms of the patients who were referred for endoscopy. After confirming the diagnosis, PPIs were given to the patients. Esomeprazole (34.66%), lansoprazole (22%), pantoprazole (18.66%), etc were prescribed frequently. After 8 weeks of treatment, repeat endoscopy revealed that the ulcer was completely healed in 65.33% of patients whereas only 6.66% had no improvement. Conclusion: The majority of the patient are almost cured of PUD by receiving various types of PPIs which are very effective drugs for healing peptic ulcer disease. Mediscope 2023;10(1): 22-30

SPATIAL CONCORDANCE OF LEFT AND RIGHT COLON FINDINGS IN PEDIATRIC PATIENTS WITH ULCERATIVE COLITIS AFTER TREAMTENT

Achieving endoscopic remission has become the preferred clinical endpoint in the care of inflammatory bowel disease (IBD) patients. This requires repeat colonoscopy in patients with ulcerative colitis (UC) after initiation of therapy. Recent adult data suggests findings in the left colon on flexible sigmoidoscopy can be highly predictive of the findings if a full colonoscopy was performed; however, pediatric data is lacking for this association. The primary aim our study to assess the accuracy of findings on the left colon with the right colon for repeat endoscopy in pediatric patients with UC.

Optimal endoscopic localization of colorectal neoplasms: a comparison of rural versus urban documentation practices

BackgroundColonoscopy is the gold standard for diagnosing colorectal neoplasms. However, colonoscopy is often repeated preoperatively due to non-standard documentation and inconsistent practices by index endoscopists. Repeat endoscopies result in treatment delays and can increase risks of complications. National consensus recommendations were recently developed for optimal endoscopic colorectal lesion localization. We aimed to assess baseline colonoscopy practice differences from the new recommendations with a focus on geographical variability in report quality between urban and rural referral sites.MethodsWe performed a retrospective review of patients who underwent elective surgery for colorectal neoplasms at a single institution in Winnipeg between 2007–2020. We compared endoscopy report quality to the national recommendations with charts stratified by endoscopy location. Our primary outcomes were overall report documentation completeness and use of recommended practices.ResultsOne hundred ninety-four patients were included (97 rural, 97 urban). The mean overall compliance with the recommendations for urban endoscopies was marginally better compared to rural endoscopies (50% vs. 48%, p = 0.04). Sixty-eight percent of the reports complied with tattoo indications (72% urban; 63% rural, p = 0.16). On average, reports included 29% of recommended tattoo information (30% urban; 28% rural, p = 0.25) and demonstrated 74% appropriate tattoo technique (70% urban; 81% rural, p = 0.10). Twenty-one percent of reports included photographs of lesions in accordance with the national recommendations (28% urban; 13% rural, p = 0.01).ConclusionsEndoscopists frequently omit recommended practices for optimal colorectal lesion localization. Rural reports miss more recommended information compared to urban reports. Future research is needed to facilitate province-wide high-quality endoscopy reporting for patients regardless of endoscopy location.

Over-the-Scope Clips Versus Standard Endoscopic Treatment for First Line Therapy of Non-variceal Upper Gastrointestinal Bleeding: Systematic Review and Meta-Analysis.

Over-The-Scope Clips (OTSC) use have shown promising results for first line treatment of non-variceal upper gastrointestinal bleeding (NVUGIB). We conducted this meta-analysis to compare outcomes in patients treated withOTSCversus standard endoscopic intervention for first line endoscopic treatment of NVUGIB. We reviewed several databases from inception to December 9, 2022 to identify studies comparing OTSC and standard treatments as the first line treatment for NVUGIB. The outcomes assessed included re-bleeding, initial hemostasis, need for vascular embolization, mortality, need for repeat endoscopy, 30day readmission rate, and need for surgery. Pooled risk ratios (RR) with 95% confidence intervals (CI) were calculated using random effect model. Heterogeneity was assessed by I2 statistic. We included 11 studies with 1608 patients (494 patients in OTSC group and 1114 patients in control group). OTSC use was associated with significantly lower risk of re-bleeding (RR, 0.58; 95% CI 0.41-0.82). We found no significant difference in rates of initial hemostasis (RR, 1.05; 95% CI 0.99- 1.11), vascular embolization rates (RR, 0.93; 95% CI 0.40- 2.13), need for repeat endoscopy (RR, 0.78; 95% CI 0.40-1.49), 30day readmission rate (RR, 0.59; 95% CI 0.17-2.01), need for surgery (RR, 0.81; 95% CI 0.29-2.28) and morality (RR, 0.69; 95% CI 0.38-1.23). OTSC are associated with significantly lower risk of re-bleeding compared to standard endoscopic treatments when used as first line endoscopic therapy for NVUGIB.

A142 APPROPRIATENESS OF POST-ENDOSCOPY CARE IN PATIENTS PRESENTING WITH FOOD BOLUS IMPACTIONS OVERNIGHT: A POPULATION-BASED MULTICENTER COHORT STUDY

Abstract Background Appropriate management of esophageal food bolus impactions includes endoscopic evaluation and follow-up for potential underlying esophageal pathology. Patients who present with impactions at night may not receive optimal long-term post-endoscopy care due to patient-, physician-, or system-related factors. Purpose We aimed to evaluate the appropriateness of care for patients who present with food bolus impactions after regular daytime hours. Method We conducted a retrospective, population-based, multi-center cohort study of adult patients undergoing endoscopy for food impaction between 19:00-06:59 from 2016-2018 in the Calgary Health Zone, Canada. Appropriate post-endoscopy care was defined by a composite of a follow-up clinic visit, repeat endoscopy, other appropriate investigations (e.g., manometry), or appropriate medical treatment (e.g., proton pump inhibitor). Predictors of inappropriate care were assessed using multivariable logistic regression, expressed as adjusted odds ratios (aOR) with 95% confidence intervals (CI). Result(s) A total of 323 patients underwent an after-hours or overnight endoscopy for food bolus impaction. 25.4% (82/323) of patients did not receive appropriate post-endoscopy care. Predictors of inappropriate care included rural residence (aOR 2.66 [95% CI: 1.18-6.01], p=0.02), first food bolus presentation (aOR 2.38 [95% CI: 1.04-5.44], p=0.04), and absence of a specific pathology during the index procedure (aOR 3.01 [95% CI: 0.97-9.29], p=0.05), suggesting a potential association with clinician cognitive bias. Among patients who were followed, 18.9% (35/185) had a change in the original diagnosis. Image Conclusion(s) One quarter of patients presenting with a food bolus impaction at night do not receive appropriate post-endoscopy care. System-based interventions should target this high-risk population as the diagnosis and management may change with follow-up. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

The features of gastric epithelial reactive hyperplastic lesions under magnifying endoscopy combined with narrow-band imaging

Background and purpose Gastric reactive hyperplasia (RH) is a common benign lesion of the gastric mucosa that can be resolved by conservative treatment without endoscopic intervention. Some RH lesions are indistinguishable from low-grade intraepithelial neoplasia (LGIN) lesions of gastric mucosa under endoscopy. The aim of this study was to investigate the morphological features of RH lesions under magnifying endoscopy combined with narrow-band imaging (ME-NBI). Methods A retrospective study of 653 patients with superficial suspicious lesions of gastric mucosa was performed. According to the pathological results of biopsies, the final included lesions were divided into the RH group (n = 88) and LGIN group (n = 138). We analysed the microvascular and microsurface patterns of these lesions under ME-NBI, extracted the most significant combination of endoscopic features of RH lesions, and evaluated their diagnostic performance. Results ME-NBI characteristics that could distinguish RH lesions from LGIN lesions after univariate analysis were included in multivariate logistic regression. The results showed that ten characteristics, including intervening part (IP) length homogeneity, type III gastric pit pattern and homogeneity of marginal crypt epithelium (MCE), were statistically significant. Receiver operating characteristic (ROC) analysis showed that the triad of these features was the best combination for diagnosing RH lesions with an AUC of 0.886 (95% confidence interval; 0.842–0.929), the sensitivity of 85.5% and specificity of 79.5%. Conclusions The triad of IP length homogeneity, type III pit pattern and MCE homogeneity under ME-NBI helps endoscopists to identify gastric RH lesions, thereby avoiding unnecessary biopsy and repeat endoscopy due to misjudgment of neoplastic lesions.

Bringing dietary therapy for eosinophilic oesophagitis under scientific scrutiny

In The Lancet Gastroenterology & Hepatology, Kara L Kliewer and colleagues report results from the first major multicentre, randomised trial of dietary therapy in patients with eosinophilic oesophagitis. 1 Kliewer KL Gonsalves N Dellon ES et al. One-food versus six-food elimination diet therapy for the treatment of eosinophilic oesophagitis: a multicentre, randomised, open-label trial. Lancet Gastroentrol Hepatol. 2023; (published online Feb 27.)https://doi.org/10.1016/S2468-1253(23)00012-2 Google Scholar The detailed study of patient outcomes, along with the assessment of transcriptomic and other markers, give valuable insights into the benefits and limitations of dietary therapy. Their objective evidence shows that the value of dietary therapy, in particular the six-food elimination diet (6FED), might have been overestimated in previous studies. 2 Gonsalves N Yang GY Doerfler B Ritz S Ditto AM Hirano I Elimination diet effectively treats eosinophilic esophagitis in adults; food reintroduction identifies causative factors. Gastroenterology. 2012; 142: 1451-1459 Summary Full Text Full Text PDF PubMed Scopus (480) Google Scholar , 3 Lucendo AJ Arias A Gonzalez-Cervera J et al. Empiric 6-food elimination diet induced and maintained prolonged remission in patients with adult eosinophilic esophagitis: a prospective study on the food cause of the disease. J Allergy Clin Immunol. 2013; 131: 797-804 Summary Full Text Full Text PDF PubMed Scopus (305) Google Scholar , 4 Infante J Modolell I Alcedo J et al. Step-up empiric elimination diet for pediatric and adult eosinophilic esophagitis: the 2-4-6 study. J Allergy Clin Immunol. 2018; 141: 1365-1372 Summary Full Text Full Text PDF PubMed Scopus (140) Google Scholar In their study, histological remission to less than 15 eosinophils per high-power field (eos/hpf) occurred in only 23 (34%) of 67 patients on the one-food elimination diet (1FED; eliminating animal milk) and 25 (40%) of 62 patients on the 6FED at 6 weeks. Kliewer and colleagues also show that the margin between 1FED and 6FED is not significant in terms of both histological remission and symptom improvement. Given the complexity of life when trying to avoid six foods and the great difficulty in sustaining such an effort for more than a year, this evidence on the value of keeping dietary therapy simple is important. As well as being easier to comply with, a single-food elimination diet (or perhaps a two-food elimination diet avoiding milk and wheat 2 Gonsalves N Yang GY Doerfler B Ritz S Ditto AM Hirano I Elimination diet effectively treats eosinophilic esophagitis in adults; food reintroduction identifies causative factors. Gastroenterology. 2012; 142: 1451-1459 Summary Full Text Full Text PDF PubMed Scopus (480) Google Scholar ) requires fewer repeat endoscopies than the seven endoscopies needed to determine which foods are relevant in the multifood approach. One-food versus six-food elimination diet therapy for the treatment of eosinophilic oesophagitis: a multicentre, randomised, open-label trialHistological remission rates and improvements in histological and endoscopic features were similar after 1FED and 6FED in adults with eosinophilic oesophagitis. 6FED had efficacy in just less than half of 1FED non-responders and steroids had efficacy in most 6FED non-responders. Our findings indicate that eliminating animal milk alone is an acceptable initial dietary therapy for eosinophilic oesophagitis. Full-Text PDF

P150 Identification of features associated with poor outcomes in pediatric patients with ulcerative proctitis: A Multicentre Study From the Paediatric IBD Porto Group of ESPGHAN

Abstract Background Ulcerative proctitis (UP) is an uncommon presentation in paediatric patients with ulcerative colitis, accounting for &amp;lt;10% of cases. Here we aimed to characterize the clinical features and natural history of paediatric patients with UP, and to identify predictors of poor outcomes. Methods A retrospective cohort study involving 37 sites affiliated with the IBD Interest group of ESPGHAN. Data were collected at different timepoints from patients diagnosed with UP aged &amp;lt;18 years between 01/01/2016-31/12/2020. Outcomes included time to initiation of systemic steroids, thiopurines or biologics, time to acute severe colitis (ASC), IBD-related admission and colectomy. Univariate cox regression was used to study the association between potential predictors and study outcomes. Results Two hundred and fifty patients with UP were included, with a median age at diagnosis of 14.5 (IQR 12.3-15.9) years, and a median follow-up of 2.7 (IQR 1.7-3.9) years. The most common presenting symptoms were bloody stools (94%), abdominal pain (59%) and diarrhea (53%). At diagnosis, the median pediatric ulcerative colitis activity index (PUCAI) score was 25 (IQR 20-35), and only 3 patients (1.3%) presented with ASC. Most children had normal inflammatory markers and albumin levels. the median fecal calprotectin level was 720 mcg/g (IQR 310-1800), while 16 patients (9.9%) had a calprotectin level &amp;lt;100mcg/g at diagnosis. Administration of oral or topical 5-ASA resulted in clinical remission rates of 52% and 48%, respectively, by the end of induction, while the combination of both led to remission in 73% of patients. The rates of treatment escalation to thiopurines and biologics at 1, 3 and 5 years were 11%, 27% and 45%, and 11%, 23% and 45%, respectively (Figure 1). Within 5 years from diagnosis, 20% of patients had presented with ASC. The PUCAI score at diagnosis of UP was highly associated with initiation of systemic steroids, thiopurines or biologics, as well as later ASC event and IBD admission, while a Mayo endoscopic score of 3 was associated with the initiation of biologics and subsequent ASC event and IBD admission (Table 1). Seven patients (4%) underwent colectomy by the end of follow-up. Among the 151/250 patients who had a repeat endoscopy, only 16% achieved mucosal healing and in 48% inflammation extended proximally. Cecal patch (P=0.009) and higher PUCAI score (P=0.009) at diagnosis, as well as higher PUCAI score (P=0.009) and lack of steroid-free clinical remission (P=0.005) by the end of induction were associated with proximal disease extension. Conclusion Disease burden is significant in paediatric patients that present with UP, with high rates of proximal disease extension and requirement for treatment escalation.

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.