Audrey H. Calderwood

ACG clinical guidelines: diagnosis and management of celiac disease.

This guideline presents recommendations for the diagnosis and management of patients with celiac disease. Celiac disease is an immune-based reaction to dietary gluten (storage protein for wheat, barley, and rye) that primarily affects the small intestine in those with a genetic predisposition and resolves with exclusion of gluten from the diet. There has been a substantial increase in the prevalence of celiac disease over the last 50 years and an increase in the rate of diagnosis in the last 10 years. Celiac disease can present with many symptoms, including typical gastrointestinal symptoms (e.g., diarrhea, steatorrhea, weight loss, bloating, flatulence, abdominal pain) and also non-gastrointestinal abnormalities (e.g., abnormal liver function tests, iron deficiency anemia, bone disease, skin disorders, and many other protean manifestations). Indeed, many individuals with celiac disease may have no symptoms at all. Celiac disease is usually detected by serologic testing of celiac-specific antibodies. The diagnosis is confirmed by duodenal mucosal biopsies. Both serology and biopsy should be performed on a gluten-containing diet. The treatment for celiac disease is primarily a gluten-free diet (GFD), which requires significant patient education, motivation, and follow-up. Non-responsive celiac disease occurs frequently, particularly in those diagnosed in adulthood. Persistent or recurring symptoms should lead to a review of the patients original diagnosis to exclude alternative diagnoses, a review of the GFD to ensure there is no obvious gluten contamination, and serologic testing to confirm adherence with the GFD. In addition, evaluation for disorders associated with celiac disease that could cause persistent symptoms, such as microscopic colitis, pancreatic exocrine dysfunction, and complications of celiac disease, such as enteropathy-associated lymphoma or refractory celiac disease, should be entertained. Newer therapeutic modalities are being studied in clinical trials, but are not yet approved for use in practice. Given the incomplete response of many patients to a GFD-free diet as well as the difficulty of adherence to the GFD over the long term, development of new effective therapies for symptom control and reversal of inflammation and organ damage are needed. The prevalence of celiac disease is increasing worldwide and many patients with celiac disease remain undiagnosed, highlighting the need for improved strategies in the future for the optimal detection of patients.

The Boston bowel preparation scale: a valid and reliable instrument for colonoscopy-oriented research

BACKGROUND Few bowel-preparation rating scales have been validated. Most scales were intended for comparing oral purgatives and fail to account for washing and/or suctioning by the endoscopist. This limits their utility in studies of colonoscopy outcomes, such as polyp-detection rates. OBJECTIVE To develop a valid and reliable scale for use in colonoscopy outcomes research. SETTING Academic medical center. METHODS We developed the Boston bowel preparation scale (BBPS), a 10-point scale that assesses bowel preparation after all cleansing maneuvers are completed by the endoscopist. We assessed interobserver and intraobserver reliability by using video footage of colonoscopies viewed on 2 separate occasions by 22 clinicians. We then applied the BBPS prospectively during screening colonoscopies and compared BBPS scores with clinically meaningful outcomes, including polyp-detection rates and procedure times. RESULTS The intraclass correlation coefficient (a measure of interobserver reliability) for BBPS scores was 0.74. The weighted kappa (a measure of intraobserver reliability) for scores was 0.77 (95% CI, 0.66-0.87). During 633 screening colonoscopies, the mean (SD) BBPS score was 6.0 +/- 1.6. Higher BBPS scores (> or =5 vs <5) were associated with a higher polyp-detection rate (40% vs 24%, P < .02). BBPS scores were inversely correlated with colonoscope insertion (r = -0.16, P < .003) and withdrawal (r = -0.23, P < .001) times. LIMITATIONS Single-center study. CONCLUSIONS The BBPS is a valid and reliable measure of bowel preparation. It may be well suited to colonoscopy outcomes research because it reflects the colons cleanliness during the inspection phase of the procedure.

Comprehensive validation of the Boston Bowel Preparation Scale.

BACKGROUND The Boston Bowel Preparation Scale (BBPS) is a novel bowel cleanliness rating scale that has undergone partial validation previously. OBJECTIVE To fully validate the BBPS and assess the ease of its dissemination. DESIGN Observational study. SETTING Various endoscopy units worldwide. SUBJECTS Endoscopists. METHODS Video recordings of colonoscopies with varying degrees of cleanliness were viewed twice by gastroenterologists at 1 medical center. For each video, participants assigned segment and total BBPS scores. Endoscopists worldwide were also surveyed about their experience with the BBPS after viewing an instructional video. MAIN OUTCOME MEASUREMENTS Intraclass correlation coefficients and weighted κ values assessed inter- and intrarater reliability, respectively. The BBPS was used among 983 patients undergoing screening colonoscopy. RESULTS The BBPS demonstrated near-perfect interrater reliability (intraclass correlation coefficient = 0.91) and substantial intrarater reliability (weighted κ = 0.78; 95% CI, 0.73-0.84). Among 983 colonoscopies, right and left colon segment scores of 2 or 3 had a multivariate odds ratio of 1.60 (95% CI, 1.01-2.55) and 2.58 (95% CI, 1.34-4.98), respectively, for polyp detection compared with segment scores of 0 or 1. Endoscopists from a variety of settings worldwide found the BBPS easy to implement and applicable to their patient population. LIMITATIONS Single-center reliability testing. CONCLUSIONS The BBPS is a valid and reliable instrument for assessing bowel cleanliness during colonoscopy. Segment scores may represent a standardized way to determine bowel preparation adequacy. The BBPS can be easily disseminated through the use of a brief instructional video.

An endoscopist-blinded, randomized, controlled trial of a simple visual aid to improve bowel preparation for screening colonoscopy

BACKGROUND The effect of patient education on bowel preparation for colonoscopy has not been well studied. An improvement in patient understanding of the rationale for bowel preparation before colonoscopy might enhance adherence to the prescribed bowel regimen and improve bowel preparation quality. OBJECTIVE To measure the effect of a simple educational intervention on the quality of bowel preparation during colonoscopy. DESIGN Prospective, single-center, endoscopist-blinded, randomized, controlled trial. SETTING Tertiary-care center. PATIENTS This study involved outpatients directly referred for screening colonoscopy. INTERVENTION Inclusion of a visual aid depicting both clean and dirty colons in addition to standard written colonoscopy instructions. MAIN OUTCOME MEASUREMENTS The primary outcome was the quality of the bowel preparation according to the Boston Bowel Preparation Scale (BBPS). Secondary outcomes included the need for repeat colonoscopy because of inadequate bowel preparation, insertion and withdrawal time, polyps detected, and patient tolerance of bowel preparation and colonoscopy. RESULTS We analyzed 492 patients given a visual aid and 477 controls. The percentage of colonoscopies with a BBPS score≥5 was similar in both groups (91% visual aid vs 89% control, P=.43). The odds ratio for having a BBPS≥5 in the visual aid group was 1.24 (95% CI, 0.83-1.87) compared with controls. Other secondary outcomes were similar between groups. LIMITATIONS Single-center study. CONCLUSION A simple card with photographs and text explaining the rationale for bowel preparation did not change the quality of bowel preparation in patients directly referred for screening colonoscopy. Future educational studies may need to include more interactive or intensive methods. ( CLINICAL TRIAL REGISTRATION NUMBER NCT00643682.).

Boston Bowel Preparation Scale scores provide a standardized definition of “adequate” for describing bowel cleanliness

BACKGROUND Establishing a threshold of bowel cleanliness below which colonoscopies should be repeated at accelerated intervals is important, yet there are no standardized definitions for an adequate preparation. OBJECTIVE To determine whether Boston Bowel Preparation Scale (BBPS) scores could serve as a standard definition of adequacy. DESIGN Cross-sectional observational analysis of colonoscopy data from 36 adult GI endoscopy practices and prospective survey showing 4 standardized colonoscopy videos with varying degrees of bowel cleanliness. SETTING The Clinical Outcomes Research Initiative. PATIENTS Average-risk patients attending screening colonoscopy. INTERVENTIONS Colonoscopy. MAIN OUTCOME MEASUREMENTS Recommended follow-up intervals among average-risk, screening colonoscopies without polyps stratified by BBPS scores. RESULTS We evaluated 2516 negative screening colonoscopies performed by 74 endoscopists. If the BBPS score was ≥2 in all 3 segments (N = 2295), follow-up was recommended in 10 years in 90% of cases. Examinations with total BBPS scores of 3 to 5 (N = 167) had variable recommendations. Follow-up within 1 year was recommended for 96% of examinations with total BBPS scores of 0 to 2 (N = 26). Similar results were noted among 167 participants in a video survey with pre-established BBPS scores. LIMITATIONS Retrospective study. CONCLUSION BBPS scores correlate with endoscopist behavior regarding follow-up intervals for colonoscopy. A total BBPS score ≥6 and/or all segment scores ≥2 provides a standardized definition of adequate for 10-year follow-up, whereas total scores ≤2 indicate that a procedure should be repeated within 1 year. Future work should focus on finding consensus for management of examinations with total scores of 3 to 5.

Immunization rates and vaccine beliefs among patients with inflammatory bowel disease: an opportunity for improvement.

Background:Immunosuppressive agents used to treat inflammatory bowel disease (IBD) can increase the risk for infections, several of which are preventable through vaccination. Our study aimed to describe vaccine utilization by immunosuppression status, examine reasons for vaccine refusal, and identify characteristics associated with lack of influenza vaccination in patients with IBD. Methods:We administered an online survey between February 2012 and April 2012 to an internet-based cohort of patients with IBD in the Crohns and Colitis Foundation of America Partners program. Results:During this time, 958 individuals completed the survey. The median age was 45, 72.8% were female, and 62.0% had Crohns disease. Self-reported vaccination rates were low. Those on immunosuppression (n = 514) were more likely to be counseled to avoid live vaccines (P < 0.01). However, counseling rates were low (3.5%–19.1% for various live vaccines). Among the 776 individuals who received the influenza vaccine, maintaining health (74.1%), importance of prevention (66.1%), and provider recommendation (38%) were the most frequently cited motivations. Factors associated with lack of influenza vaccine included lower education level (P = 0.01), younger age (P = 0.02), and no chronic immunosuppression use (P < 0.01). Five hundred seventy (59.5%) individuals thought that patients were responsible for keeping track of their vaccines, whereas 428 (44.7%) placed responsibility on their gastroenterologist and 595 (62.1%) on their primary care physician. Conclusions:Vaccine utilization remains suboptimal in patients with IBD. Educational interventions may increase vaccination rates by clarifying misconceptions. Gastroenterologists can play a more active role in health care maintenance in patients with IBD by counseling patients on which vaccines to receive or avoid.

Guidelines for Safety in the Gastrointestinal Endoscopy Unit

In 2009, the Centers for Medicare and Medicaid Services (CMS) Conditions for Coverage eliminated the distinction between a sterile operating room and a non-sterile procedure room. Hence, GI endoscopy units are now held to the same standards as sterile operating rooms by CMS1 without evidence demonstrating that safety or clinical outcomes in endoscopy are thereby improved. Although the ASGE has previously published guidelines on staffing, sedation, infection control, and endoscope reprocessing for endoscopic procedures (Multisociety guideline on reprocessing flexible gastrointestinal endoscopes: 2011; Infection control during GI endoscopy; Minimum staffing requirements for the performance of GI endoscopy; Multisociety sedation curriculum for gastrointestinal endoscopy)2, 3, 4, 5 the purpose of this document is to present recommendations for endoscopy units in implementing and prioritizing safety efforts and to provide an endoscopy-specific guideline by which to evaluate endoscopy units. As a general principle, requirements for safety ought to be rooted in evidence that demonstrates a benefit in outcomes. Where data is absent, these requirements may be derived from experts with experience in the safe delivery of care in the GI endoscopy setting. Additionally, consideration should be given to the promotion of efficient care and cost containment with avoidance of requirements unsupported by evidence that then contribute to rising healthcare costs. Over the past 2 years, surveyors have called into question accepted practices at many accredited endoscopy units seeking re-accreditation. Many of these issues relate to the Ambulatory Surgical Center (ASC) Conditions for Coverage set forth by CMS and the lack of distinction between the sterile operating room and the endoscopy setting. The following is a summary of issues that have been faced by endoscopy units throughout the country along with ASGE’s position and accompanying rationale. Issue: Structural requirements for 40-inch doors and room sizes >400 square feet required of sterile operating rooms. Position: Standard 36-inch doors, if they accommodate patient transport mechanisms, and room sizes 180 square feet are adequate and safe for endoscopy units because they do not use the same large equipment or number of staff as in the operating room.6 Issue: Requirement for a written policy on traffic patterns in the endoscopy unit. Position: The unit should define low-risk exposure and high-risk exposure areas and activities within the endoscopy unit, and describe the attire and personal protective equipment that should be worn in each area. Endoscopy staff can move freely throughout the unit provided that there is appropriate use and changing of personal protective equipment. Issue: Requirement for endoscopy personnel to don full sterile operating room personal protective equipment including new scrubs, hair covers and booties. Position: It is recommended that staff directly engaged in GI endoscopy or in processes where splash or contamination could occur should wear gloves, face/eye shields, and an impervious gown. Units should develop policies that are consistent with OSHA and state-mandated recommendations for wearing face/eye shields or masks.7 Scrubs or other attire may be worn from home because endoscopy is not a sterile procedure. Likewise, there is no need for hair covers or booties. Staff must remove and appropriately discard used PPE before leaving the procedure area. Issue: Supervision of moderate sedation. Position: Moderate sedation may be administered safely under the supervision of a non-anesthesia physician who is credentialed and privileged to do so. Issue: Role of capnography. Position: There is inadequate data to support the routine use of capnography where moderate sedation is the target. Issue: Requirement that 2 nurses (one monitoring, one circulating) are present when moderate sedation is performed. Position: When moderate sedation is the target, a nurse should monitor the patient and can perform interruptible tasks. If more technical assistance is required, a second assistant (nurse, licensed practical nurse, or unlicensed assistive personnel) should be available to join the care team. Issues: Staffing requirements when sedation and monitoring is provided by anesthesia personnel. Position: When sedation and monitoring is provided by anesthesia personnel, a single additional staff person (nurse, licensed practical nurse, or unlicensed assistive personnel) is sufficient to assist with technical aspects of the procedure. Issue: Technical capabilities of technicians. Position: Unlicensed technicians, who have received initial orientation and ongoing training, and are deemed competent by their unit, can assist with and participate in tissue acquisition during the endoscopic procedure, including but not limited to the opening and closing of forceps, snares, and other accessories.

Female authorship in major academic gastroenterology journals: a look over 20 years

BACKGROUND Authorship in peer-reviewed medical journals is a marker for success in academic medicine. OBJECTIVE To determine the representation of female physicians among authors of original research in U.S. gastroenterology journals. DESIGN Retrospective. SUBJECTS All first and senior U.S. authors of original research published in the years 1992, 1997, 2002, 2007, and 2012 in the following journals: Gastroenterology, Hepatology, American Journal of Gastroenterology, Clinical Gastroenterology and Hepatology (CGH), and Gastrointestinal Endoscopy (GIE). MAIN OUTCOME MEASUREMENTS The percentage of female first and senior authors compared with the percentage of women practicing in academic gastroenterology. RESULTS We evaluated 6490 articles, of which 2275 original research articles and 455 editorials were eligible for inclusion. Author gender was determined for 98.5% of the 3792 authors. Overall, female first authors increased from 9.1±2.9% in 1992 to 29.3±4.9% in 2012 (P<.0001), and female senior authors increased from 4.8±2.3% in 1992 to 14.5±3.6% in 2012 (P<.0001). Female first and senior authors increased significantly in all journals (P for trend<.05), except for CGH, and CGH and GIE, respectively. For each of the years examined with the exception of 1997, the proportion of women in the senior author position was less than expected based on the proportion of women among academic gastroenterologists (P<.004; P=.18 for 1997). LIMITATIONS Descriptive study. CONCLUSIONS The percentage of U.S. female physician authors of original research in major gastroenterology journals has increased over time, yet the percentage of women in the senior author position remains lower than expected. Further research should explore potential reasons for this gender gap.

Colonoscopy Quality: Metrics and Implementation

Colonoscopy is an excellent area for quality improvement because it is high volume, has significant associated risk and expense, and there is evidence that variability in its performance affects outcomes. The best end point for validation of quality metrics in colonoscopy is colorectal cancer incidence and mortality, but a more readily accessible metric is the adenoma detection rate. Fourteen quality metrics were proposed in 2006, and these are described in this article. Implementation of quality improvement initiatives involves rapid assessments and changes on an iterative basis, and can be done at the individual, group, or facility level.

Validity of a web-based educational program to disseminate a standardized bowel preparation rating scale

Goals: Our goal was to assess the validity of a Web-based educational program on the Boston Bowel Preparation Scale (BBPS). Background: Data on Web-based education for improving the practice and quality of colonoscopy are limited. Study: Endoscopists worldwide participated in the BBPS Educational Program. We assessed program completion rates, satisfaction, short-term (0 to 90 d) and long-term (91 to 180 d) uptake of the BBPS, and the validity of the program by measuring the reliability of the BBPS among participants. Results: A total of 207 endoscopists completed the program. Overall, 93% found the content relevant, 89% felt confident in using the BBPS, and 97% thought the quality was good or excellent. Uptake of the BBPS into clinical practice was robust with 91% and 98% of colonoscopy reports containing the BBPS at short-term and long-term follow-up, respectively. The interobserver and test-retest reliability of BBPS segment and total scores were both substantial. Conclusions: A BBPS Web-based educational program facilitates adoption into clinical practice and teaches the BBPS to be used reliably by a diverse group of endoscopists worldwide.