Jack Amar

Prospective analysis of fluoroscopy duration during ERCP: critical determinants

BACKGROUND Fluoroscopy during ERCP has a linear relationship with radiation, carrying risk of exposure. OBJECTIVE To determine patient, physician, and procedural factors affecting fluoroscopy duration. DESIGN Prospective analysis of ERCPs with evaluation of patient, physician, and procedural variables. SETTING Two tertiary-care hospitals. PATIENTS Consecutive patients undergoing ERCP. INTERVENTIONS ERCP. MAIN OUTCOME MEASUREMENTS Variables associated with prolonged fluoroscopy duration. RESULTS Mean fluoroscopy time (388 ERCPs) was 6.77 minutes (95% CI, 6.15-7.39). No patient factors were found to significantly affect fluoroscopy duration. Fluoroscopy duration was significantly lower for 2 endoscopists compared with the reference endoscopist (average of 4.16 minutes less; 95% CI, -5.48 to -2.48). Multivariable analysis identified variables associated with longer fluoroscopy duration; stent insertion (+3.11 minutes; 95% CI, 1.91-4.30), lithotripsy (+5.74 minutes; 95% CI, 0.931-10.5), needle-knife sphincterotomy (+4.44 minutes; 95% CI, 2.20-6.67), biopsies (+2.11 minutes; 95% CI, 0.025-4.18), use of a guidewire (+1.55 minutes; 95% CI, 0.025-3.07), additional guidewires (+5.61 minutes; 95% CI, 2.69-8.51), and balloon catheter (+4.27 minutes; 95% CI, 3.00-5.53). Mean fluoroscopy duration when a gastroenterology fellow was involved (n = 318) was 7.05 minutes (95% CI, 6.35-7.76) compared with 5.44 minutes (95% CI, 4.26-6.63) when no fellow present (n = 70) (P < .0451). LIMITATIONS Only 2 centers; others may have different results. Not blinded; investigators may change their practice because fluoroscopy was duration studied. Irrelevance of measuring fluoroscopy duration because endoscopists using protection may not have increased radiation exposure. CONCLUSIONS In this prospective analysis, factors associated with fluoroscopy duration included endoscopists; stent insertion; lithotripsy; biopsies; use of a needle-knife, guidewire, and balloon catheter; and involvement of a gastroenterology fellow. These identified variables may help endoscopists predict which procedures are associated with prolonged fluoroscopy duration and may lead to appropriate precautions.

A randomized controlled trial assessing the effect of prescribed patient position changes during colonoscope withdrawal on adenoma detection

BACKGROUND High-quality colonoscope withdrawal technique is associated with a higher adenoma detection rate. Position change is routinely used in barium enema and CT colonography to facilitate adequate distension of the colon and promote movement of fluid from the segment of the colon being assessed. OBJECTIVE To determine whether prescribed position changes during colonoscope withdrawal affect the adenoma detection rate compared with the usual care per endoscopist. DESIGN Prospective, randomized, controlled trial. SETTING Tertiary-care, university-affiliated hospital. PATIENTS Patients referred for outpatient colonoscopy between July 2011 and July 2012 were evaluated for eligibility. Inclusion criteria were outpatient status and age ≥40 years. Exclusion criteria were (1) complete colonoscopy within 1 year before the procedure, (2) inability to provide informed consent, (3) incomplete colonoscopy to the cecum, (4) previous bowel resection, (5) inflammatory bowel disease, (6) colonic polyposis syndrome, (7) inadequate bowel preparation, and (8) musculoskeletal disorder or other mobility issues limiting effective patient position changes during colonoscopy. INTERVENTIONS Prescribed position changes during colonoscope withdrawal. MAIN OUTCOME MEASUREMENTS Polyp detection rate (PDR) and adenoma detection rate (ADR). RESULTS A total of 776 patients were enrolled, with 388 in the dynamic group. There was no difference in PDR (odds ratio [OR] 0.99; P = .93) or ADR (OR 1.17; P = .28). Colonoscope withdrawal time was longer in the dynamic group (median time 466.5 vs 422.5 seconds; P < .0001). LIMITATIONS Single-center study. Indication for procedure not controlled. Lack of standardized bowel preparation and blinding. CONCLUSION Prescribed position changes during colonoscope withdrawal do not affect polyp/adenoma detection compared with the usual practice when the baseline ADR is above the recommended standard. ( CLINICAL TRIAL REGISTRATION NUMBER NCT01395173.).

Prospective evaluation of screening colonoscopy: who is being screened?

BACKGROUND Universal access to medical procedures is deemed an advantage of the Canadian health care system. The purposes of this prospective study were to determine the degree to which the practice of colon cancer screening by colonoscopy differed among socioeconomic classes and to assess adherence to screening guidelines. METHODS Consecutive patients scheduled to undergo colonoscopy at a single center between August 2000 and August 2002 completed a questionnaire that determined patient characteristics and indications for the procedure. The patients were divided into two groups: screening patients, defined as individuals who indicated they were undergoing colonoscopy for screening purposes and were asymptomatic, and a control group, which comprised patients undergoing colonoscopy because of symptoms. Statistical analysis was performed to determine if patients in the screening group had different characteristics with respect to socioeconomic class, compared with the control group. RESULTS A total of 1088 patients completed the questionnaire: 707 (65%) had colonoscopy because of symptoms, compared with 381 (35%) who underwent a screening examination. Mean age and marital status were similar in both groups. Of all colonoscopy procedures, there was a significantly greater proportion of men undergoing colonoscopy for screening purposes: 199 (52.2%) vs. 294 (41.6%) in the symptomatic group ( p = 0.001). Based on the Cochran-Armitage test, patients in the screening group had significantly higher education levels ( p = 0.004) and household incomes ( p = 0.001). CONCLUSIONS Income and education level, two indices of socioeconomic status, are statistically significantly higher in patients undergoing screening colonoscopy compared with those having colonoscopy for any other reason.

Systemic Amyloidosis: A Rare Presentation of Mesenteric Angina

A 64-year-old man presented with an eight-month history of increasing postprandial epigastric pain and a 15 kg weight loss. Computed tomography of the abdomen, panendoscopy and mesenteric angiography failed to explain the cause of the patients mesenteric angina. Systemic amyloidosis involving intestinal small vasculature without larger arterial involvement was diagnosed at autopsy after the patient died of an asystolic cardiac arrest. Mesenteric angina without evidence of ischemic enteritis or pseudo-obstruction is a rare manifestation of amyloidosis.

3383 Upper gastrointestinal endoscopy in hiv patients: indications and diagnostic yield in an era of highly active antiretroviral therapy (haart).

The advent of HAART has dramatically changed the progression of HIV disease. With the addition of protease inhibitors (PI) in 1997, certain disorders of the gastrointestinal (UGI) tract associated with advanced HIV disease (candida, wasting syndrome, AIDS-related diarrhea) appear to be much less common. We reviewed our experience with upper endoscopy in HIV patients since 1997 to determine: 1) the primary indications for upper GI procedures 2) the diagnostic and therapeutic yield of upper GI endoscopy 3) if patients on HAART had less HIV-related findings than those not on antiretroviral therapy. Methods: All patients, known to be HIV-positive, who had an UGI endoscopic procedure performed between 01/97 to 09/99 were identified through a computerized database. Data collected included: medications, CD4 count, comorbid diseases, indication for procedure, endoscopic and pathological diagnosis and therapy initiated. Results: 127 upper endoscopic procedures were performed. The mean CD4 count was 325 (range 0-900) cells/μl and 54% of the patients were on HAART. The most common indications for the procedures were pain (33%), dysphagia (22%), bleeding (22%) and diarrhea (17%). In endoscopies performed in patients presenting with pain, 43% were normal, 29% had esophagitis (19% candida-related) and 19% had either gastritis or gastric erosions. In those presenting with dysphagia, esophagitis was found in 66% (reflux-52%, candida-14%), 19% were normal and 7.5% had esophageal ulcers. In those with diarrhea, 57% had normal upper endoscopies and histology. An etiology of diarrhea was found in 19% (bacillary angiomatosis-2, subtotal villous atrophy-1, cryptosporidiosis-1). The highest yield of positive endoscopic results were seen in bleeding patients where 96% of patients had an etiology of bleeding discovered (esophageal or gastric varices-75%). Overall, 22% of patients had HIV-specific UGI endoscopic findings. Of these significantly more were found in patients not on antiretroviral therapy (14%) than those on HAART (7.8%). Conclusions: Since the initiation of HAART, the most common indications for upper endoscopy in HIV patients are abdominal pain, dysphagia, bleeding and diarrhea. Endoscopies performed on those patients presenting with UGI bleeding have the highest diagnostic yield and those presenting with pain the lowest. HIV-specific diagnosis are found more commonly in those HIV patients not taking HAART.

Prospective evaluation of screening colonoscopy: Evidence against universal access

and for more or less educated patients (25% vs. 23%, p =ns). Conclusions: Primary care physicians were less likely to recommend CRC screening to African-American and less educated patients in the equal access VA system. However, preliminary results indicate that adherence to screening did not vary by race or educational level. Lower CRC screening rates among minority and less educated patients may be due to lack of a physician recommendation. Physician-targeted educational efforts may be required in order to increase CRC screening rates among minority and less educated groups.