Jessica Tong

Factors Associated With Positive Findings From Capsule Endoscopy in Patients With Obscure Gastrointestinal Bleeding

BACKGROUND & AIMS Capsule endoscopy (CE) is used most frequently to identify causes of obscure gastrointestinal bleeding (OGIB). Identifying factors associated with the detection of lesions by CE could improve resource utilization and thereby improve patient selection for CE examination. We sought to identify clinical factors associated with positive findings from CE in patients with OGIB. METHODS We analyzed data from 698 CE procedures performed between December 2001 and April 2011 at St Pauls Hospital, Vancouver, Canada (50.3% of patients were female; mean age, 63.4 years). A positive finding was defined as a lesion that was believed to be the source of the bleeding (ulceration, mass lesion, vascular lesion, or visible blood). Univariate and multivariate logistic regression analyses were used to correlate demographic and clinical parameters with positive findings. RESULTS A lesion believed to be the cause of bleeding was identified in 42% of cases. In univariate analysis, the number of esophagogastroduodenoscopies (EGDs), the presence of connective tissue disease or diabetes with end-organ damage, Charlson comorbidity index scores, and increasing transfusion requirements were significantly associated with identification of causative pathology from CE (all P < .027). In multivariate analysis, increasing number of EGDs (odds ratio [OR], 1.17; 95% confidence interval [CI], 1.00-1.37), increasing transfusion requirements (3-9 units: OR, 1.70; 95% CI, 1.08-2.66, and ≥10 units: OR, 2.72; 95% CI, 1.69-4.37), and connective tissue disease (OR, 2.24; 95% CI, 1.14-4.41) were all significantly associated with identification of positive findings by using CE (all P < .045). CONCLUSIONS Patients with a higher number of precapsule EGDs or transfusions, or connective tissue disease, are superior candidates for analysis of OGIB by CE.

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.).

Incomplete Colonoscopy: Maximizing Completion Rates of Gastroenterologists

BACKGROUND Cecal intubation is one of the goals of a quality colonoscopy; however, many factors increasing the risk of incomplete colonoscopy have been implicated. The implications of missed pathology and the demand on health care resources for return colonoscopies pose a conundrum to many physicians. The optimal course of action after incomplete colonoscopy is unclear. OBJECTIVES To assess endoscopic completion rates of previously incomplete colonoscopies, the methods used to complete them and the factors that led to the previous incomplete procedure. METHODS All patients who previously underwent incomplete colonoscopy (2005 to 2010) and were referred to St Pauls Hospital (Vancouver, British Columbia) were evaluated. Colonoscopies were re-attempted by a single endoscopist. Patient charts were reviewed retrospectively. RESULTS A total of 90 patients (29 males) with a mean (± SD) age of 58 ± 13.2 years were included in the analysis. Thirty patients (33%) had their initial colonoscopy performed by a gastroenterologist. Indications for initial colonoscopy included surveillance or screening (23%), abdominal pain (15%), gastrointestinal bleeding (29%), change in bowel habits or constitutional symptoms (18%), anemia (7%) and chronic diarrhea (8%). Reasons for incomplete colonoscopy included poor preparation (11%), pain or inadequate sedation (16%), tortuous colon (30%), diverticular disease (6%), obstructing mass (6%) and stricturing disease (10%). Reasons for incomplete procedures in the remaining 21% of patients were not reported by the referring physician. Eighty-seven (97%) colonoscopies were subsequently completed in a single attempt at the institution. Seventy-six (84%) colonoscopies were performed using routine manoeuvres, patient positioning and a variable-stiffness colonoscope (either standard or pediatric). A standard 160 or 180 series Olympus gastroscope (Olympus, Japan) was used in five patients (6%) to navigate through sigmoid diverticular disease; a pediatric colonoscope was used in six patients (7%) for similar reasons. Repeat colonoscopy on the remaining three patients (3%) failed: all three required surgery for strictures (two had obstructing malignant masses and one had a severe benign obstructing sigmoid diverticular stricture). CONCLUSION Most patients with previous incomplete colonoscopy can undergo a successful repeat colonoscopy at a tertiary care centre with instruments that are readily available to most gastroenterologists. Other modalities for evaluation of the colon should be deferred until a second attempt is made at an expert centre.

Diagnostic yield of capsule endoscopy in the setting of iron deficiency anemia without evidence of gastrointestinal bleeding

BACKGROUND The diagnostic yield of capsule endoscopy (CE) in the setting of iron deficiency anemia (IDA) without evidence of occult⁄overt bleeding has been questioned. Often, these patients have nongastrointestinal causes of iron deficiency but undergo CE to exclude a potential small bowel source. OBJECTIVE To assess the diagnostic yield of CE, the characteristics predicting positive results, the presumed etiology of IDA in negative⁄normal CE and patient management after CE. METHODS A retrospective review of 934 patients who underwent CE between December 2001 and February 2010 was conducted. All patients had undergone previous negative endoscopic examinations before CE. Patients with IDA but no evidence of overt⁄occult bleeding were separated into three categories based on CE findings: group A - positive; group B - negative⁄normal; and group C - incomplete⁄indeterminate. RESULTS A total of 101 capsules in 97 patients were evaluated. Group A had 25 subjects with positive findings on CE, 18 of whom were managed supportively. Group B consisted of 69 subjects with negative⁄normal CE, 60 of whom were treated supportively. Group C consisted of three subjects with incomplete CE results. CONCLUSION In patients with IDA without evidence of gastrointestinal bleeding, CE had a low diagnostic yield (25.7%), which increased to 45.5% after adjusting for low dietary iron intake and menorrhagia. However, CE did not alter management in most patients regardless of findings, and many of the lesions requiring intervention were within reach of standard endoscopes. No predictor of positive results was found. In this patient population, careful history taking and thorough endoscopy could improve CE utilization, although its value is still relatively limited.

Capsule Endoscopy for Obscure Gastrointestinal Bleeding in Patients with Comorbid Rheumatic Diseases

Background and Aim. We evaluated the association between patients with rheumatic diseases (RD) suffering from obscure gastrointestinal bleeding (OGIB) and positive capsule endoscopy (CE) findings. Methods. All CE procedures performed on patients with RD and OGIB were assessed from a large database at St. Pauls Hospital (Vancouver, BC, Canada) between December 2001 and April 2011. A positive finding on CE was defined as any pathology, including ulcers/erosions, vascular lesions, and mass lesions, perceived to be the source of bleeding. Results. Of the 1133 CEs performed, 41 (4%) complete CEs were for OGIB in patients with RD. Of these, 54% presented with overt bleeding. Mean age was 66 years. Positive findings were seen in 61% of patients. Ulcerations/erosions (36%) and vascular lesions (36%) were the most common findings. Significant differences between the RD versus non-RD populations included: inpatient status, nonsteroidal anti-inflammatory drug (NSAIDs) use, oral steroid use, and mean Charlson index score (all P ≤ 0.008). Similar nonsignificant trends were seen between positive and negative CEs among the RD population. Conclusions. The correlation between RD and positive CE findings is likely influenced by ongoing anti-inflammatory drug use, poorer health status, and a predisposition for angiodysplastic lesions.

Identification of factors associated with sedation tolerance in 5000 patients undergoing outpatient colonoscopy: Canadian tertiary center experience

AIM To develop a prediction model aimed at identifying patients that may require higher than usual sedation doses during colonoscopy. METHODS A retrospective chart review on 5000 patients who underwent an outpatient colonoscopy at St. Paul’s Hospital from 2009 to 2010 was conducted in order to develop a model for identifying patients who will require increased doses of sedatives. Potential predictor variables including age, gender, endoscopy indication, high sedation requirements during previous endoscopies, difficulty of the procedure, bowel preparation quality, interventions, findings as well as current use of benzodiazepines, opioids and alcohol were analyzed. The outcome of study was the use of high dose of sedation agents for the procedure. In particular, the high dose of sedation was defined as fentanyl greater than 50 mcg and midazolam greater than 3 mg. RESULTS Analysis of 5282 patients (mean age 57 ± 12, 49% female) was performed. Most common indication for the procedure was screening colonoscopy (57%). Almost half of our patients received doses exceeding Fentanyl 50 mcg and Midazolam 3 mg. Logistic regression models identified the following variables associated with high sedation: Younger age (OR = 0.95 95%CI: 0.94-0.95; P < 0.0001); abdominal pain (OR = 1.45, 95%CI: 1.08-1.96); P = 0.01) and Inflammatory Bowel Disease (OR = 1.45, 95%CI: 1.04-2.03; P = 0.02) as indications for the procedure; difficult procedure as defined by gastroenterologist (OR = 1.73, 95%CI: 1.48-2.03; P < 0.0001); past history of abdominal surgery (OR = 1.33, 95%CI: 1.17-1.52; P <0.0001) and previous colonoscopy (OR = 1.39, 95%CI: 1.21-1.60; P = 0.0001) and alcohol use (OR = 1.26, 95%CI: 1.03-1.54; P = 0.02). Age and gender adjusted analysis yielded inflammatory bowel disease as an indication (OR = 3.17, 95%CI: 1.58-6.37; P = 0.002); difficult procedure as defined by an endoscopist (OR = 5.13 95%CI: 2.97-8.85; P = 0.0001) and current use of opioids, benzodiazepines or antidepressants (OR = 2.88, 95%CI: 1.74-4.77; P = 0.001) having the highest predictive value of high sedation requirements. Our prediction model using the following pre-procedural variables including age, gender, indication for the procedure, medication/substance use, previous surgeries, previous high sedation requirements for colonoscopy yielded an area under the curve of 0.76 for Fentanyl ≥ 100 mcg and Midazolam ≥ 3 mg. CONCLUSION Pre-procedural planning is the key in conducting successful, efficient colonoscopy. Logistic regression analysis of 5000 patients who underwent out-patient colonoscopy revealed the following factors associated with increased sedation requirement: Younger age, female gender, difficult endoscopy, specific indications as well as cardiopulmonary complications and current use of opioids/benzodiazepines. Age and gender adjusted analysis yielded similar results. These patients are more likely to need a longer recovery periods post-endoscopy, which could result in additional time and personnel requirements. The final predictive model has good predictive ability for Fentanyl ≥ 100 mcg and Midazolam ≥ 3 mg and fair predictive ability for Fentanyl ≥ 50 mcg and Midazolam ≥ 2 mg. The external validity of this model is planned to be tested in another center.

Su1721 Helicobacter pylori - Do We Eradicate HP in Hospitalized Patients With Peptic Ulcer Disease

Introduction: The increasing levels of antibiotic resistance have increased the need to develop new first-line treatments for Helicobacter pylori. We prospectively evaluate the 10-day sequential and conventional triple therapy. Methods: One hundred and fifty-nine patients who had peptic ulcer diseases confirmed by endoscopy were prospectively randomized to receive 10days of lansoprazole, amoxicillin, and clarithromycin (conventional therapy, CT) or 5 days of lansoprazole and amoxicillin followed by 5 days of lansoprazole , clarithromycin, and metronidazole (sequential therapy, ST). The post-treatmentH. pylori status was determined by the 13C-urea breath test. The eradication rates, antibiotics resistance rate, drug compliance, and side effects of each group were evaluated. Results: The intention-to-treat eradication rates were 75.9% (95% CI:66.5%-85.3%, 60/79) in the ST and 58.7.% (95% CI 78.292.0%,47/80) in the CT (P=0.01), while the per-protocol eradication rates were 86.8% (95% CI: 78.7%-94.8%, 59/68) and 67.6% (95% CI 56.5%-78.7%,46/68) (P=0.01), respectively. The number of patients having side effects was similar between both groups. In culture result, clarithromycin resistance was 19.5% (8/41) and metronidazole resistance was 41.4% (17/41), respectively. Conclusions: 10-day ST showed higher eradication rates than 10day conventional triple therapy. However, ST did not achieve satisfactory eradication rate. Therefore, more effective regimen would be required to overcome antibiotic resistance.