Kanwarpreet Tandon

Endoscopic botox injections in therapy of refractory gastroparesis

Gastroparesis (GP) is a common disease seen in gastroenterology practice particularly in western countries, and it may be underdiagnosed. The available drug therapies for this condition are quite disappointing. Botulinum toxin type A (BT) has been found to be effective therapy in various spastic disorders of smooth muscle of gastrointestinal tract. However, the benefits of BT injections in GP have been unclear. Several retrospective and open label studies have shown clinical advantages of intrapyloric Botulinum toxin type A injections, while two small randomized trials did not show positive results. Therefore, the available published studies yielded conflicting results leading to fading out of botox therapy for GP. We recognize possible clinical benefit of BT injections without any disadvantages of this treatment. We are calling for revisiting the endoscopy guided botox therapy in refractory GP. In this review we discuss important features of these studies pointing out differences in results among them. Differences in patient selection, doses and method of administration of botox toxin in the prior studies may be the cause of conflicting results. The mechanism of action, indications, efficacy and side-effects of BT are reviewed. Finally, we recognize limited evidence to recommend BT in GP and calling attention for future research in this field since no advances in drug management had been made in the last two decades.

Body mass index and colon cancer screening: The road ahead

Screening for colorectal cancer (CRC) has been associated with a decreased incidence and mortality from CRC. However, patient adherence to screening is less than desirable and resources are limited even in developed countries. Better identification of individuals at a higher risk could result in improved screening efforts. Over the past few years, formulas have been developed to predict the likelihood of developing advanced colonic neoplasia in susceptible individuals but have yet to be utilized in mass screening practices. These models use a number of clinical factors that have been associated with colonic neoplasia including the body mass index (BMI). Advances in our understanding of the mechanisms by which obesity contributes to colonic neoplasia as well as clinical studies on this subject have proven the association between BMI and colonic neoplasia. However, there are still controversies on this subject as some studies have arrived at different conclusions on the influence of BMI by gender. Future studies should aim at resolving these discrepancies in order to improve the efficiency of screening strategies.

Can adjusting BMI for age and sex provide for a better predictor of colonic neoplasia

Objective The aim of this study was to evaluate the influence of BMI on colonic neoplasia in average-risk patients aged between 40 and 59 years, analyzed by sex. Methods A total of 4443 patients aged between 40 and 59 years undergoing a first-time screening or average-risk colonoscopy were included in this study. Data on demographics, smoking, and BMI were collected and correlated to the presence of adenomas and advanced adenomas. Results We evaluated 1197 colonoscopies in patients aged between 40 and 49 years, and 3246 in those aged between 50 and 59 years. Among men between 40 and 49 years, increasing BMI [odds ratio (OR)=1.05, 95% confidence interval (CI): 1.00–1.09] and BMI of at least 27 (OR=1.95, 95% CI: 1.15–3.29) were predictors of adenomas. Younger men with a BMI of at least 27 were more likely to have proximal adenomas (OR=2.23, 95% CI: 1.14–4.37) but not advanced adenomas. There was no relation between BMI and adenomas in younger women. Among women aged between 50 and 59 years, increasing BMI (OR=1.03, 95% CI: 1.01–1.05) and a BMI of at least 24 (OR=1.43, 95% CI: 1.06–2.94) was found to be correlated with adenomas, and increasing BMI was also found to be associated with proximal adenomas (OR=1.67, 95% CI: 1.13–2.45). Among men aged between 50 and 59 years, there was no relation between BMI and adenomas, but there was a positive correlation for advanced adenomas (OR=1.05, 95% CI: 1.002–1.09). Among women aged between 50 and 59 years, BMI was not predictive of advanced adenomas. Conclusion The association between BMI and adenoma differs by age and sex. If BMI is utilized to refine screening practices for colorectal cancer, its influence on sex and age should be taken into account.

A New Scoring System to Predict the Risk for High-risk Adenoma and Comparison of Existing Risk Calculators.

Background: Colorectal cancer (CRC) screening guidelines likely over-generalizes CRC risk, 35% of Americans are not up to date with screening, and there is growing incidence of CRC in younger patients. Goals: We developed a practical prediction model for high-risk colon adenomas in an average-risk population, including an expanded definition of high-risk polyps (≥3 nonadvanced adenomas), exposing higher than average-risk patients. We also compared results with previously created calculators. Study: Patients aged 40 to 59 years, undergoing first-time average-risk screening or diagnostic colonoscopies were evaluated. Risk calculators for advanced adenomas and high-risk adenomas were created based on age, body mass index, sex, race, and smoking history. Previously established calculators with similar risk factors were selected for comparison of concordance statistic (c-statistic) and external validation. Results: A total of 5063 patients were included. Advanced adenomas, and high-risk adenomas were seen in 5.7% and 7.4% of the patient population, respectively. The c-statistic for our calculator was 0.639 for the prediction of advanced adenomas, and 0.650 for high-risk adenomas. When applied to our population, all previous models had lower c-statistic results although one performed similarly. Conclusions: Our model compares favorably to previously established prediction models. Age and body mass index were used as continuous variables, likely improving the c-statistic. It also reports absolute predictive probabilities of advanced and high-risk polyps, allowing for more individualized risk assessment of CRC.

Safety of Large-volume, Same-day Oral Bowel Preparations During Deep Sedation: A Prospective Observational Study

BACKGROUND: Colonoscopy quality is directly related to the bowel preparation. It is well established that bowel preparations are improved when at least part of the laxative is ingested on the day of the procedure. However, there is concern that this can result in higher gastric residual volumes (GRV) and increase the risk of pulmonary aspiration. The aim of this study is to evaluate GRV and gastric pH in patients who received day-before bowel preparation versus those ingesting their laxative on the day of colonoscopy under anesthesiologist-directed propofol deep sedation. METHODS: This is a prospective observational study for patients undergoing same-day upper endoscopy and colonoscopy. All included patients had large-volume polyethylene glycol lavage preparation and received propofol sedation. Gastric fluid was collected during the upper endoscopy for volume and pH measurement. RESULTS: The study included 428 patients with 56% receiving same-day laxative preparation and the remainder evening-before preparation. Mean ± SD GRV was 18.1 ± 10.2 mL, 16.3 ± 16.5 mL in each of these preparation groups, respectively (P = .69). GRV ≥ 25 mL or higher than expected GRV adjusted by weight (0.4 mL/kg) were also not different among the study groups (P = .90 and P = .87, respectively). Evaluating GRV based on time since last ingestion of preparation (3–5, 5–7, >7 hours) did not result in any differences (P = .56). Gastric pH was also similar between the bowel preparation groups (P = .23), with mean ± SD of 2.5 ± 1.4 for evening-before and 2.5 ± 1.3 for the same-day preparation. There were more inadequate bowel preparations in day before bowel preparations (P = .001). CONCLUSIONS: A large-volume bowel preparation regimen finished on the day of colonoscopy as close as 3 hours before the procedure results in no increase in GRV or decrease in gastric pH.

Crohn's disease presenting as acute gastrointestinal hemorrhage

Severe gastrointestinal (GI) hemorrhage is a rare complication of Crohns disease (CD). Although several surgical and non-surgical approaches have been described over the last 2 decades this complication still poses significant diagnostic and therapeutic challenges. Given the relative infrequency of severe bleeding in CD, available medical literature on this topic is mostly in the form of retrospective case series and reports. In this article we review the risk factors, diagnostic modalities and treatment options for the management of CD presenting as GI hemorrhage.

Comparison of Adenoma Detection Rates in Afro-Caribbeans and Non-Hispanic Whites Undergoing First Screening Colonoscopy.

Objectives The African American population has a higher prevalence of advanced colon adenomas when compared with non-Hispanic whites and Hispanics, but the risk in other black populations has not been evaluated. Although the Afro-Caribbean population is a significant demographic segment in some regions of the United States, the data are limited on the prevalence of colon adenomas in this group and there is no comparison with a non-Hispanic white population. The objective of our study was to compare the prevalence of adenomas in Afro-Caribbean versus non-Hispanic white populations. Methods A total of 880 Afro-Caribbean patients and 1828 non-Hispanic white patients undergoing their first screening colonoscopy between January 2008 and August 2014 was included in the study. Results A total of 2708 patients met entry criteria for the study. The adenoma detection rate among Afro-Caribbeans was 29% and 31% among non-Hispanic whites. There was no statistically significant difference in the prevalence of adenomas in the two groups (P = 0.28), and the rate of advanced adenomas also was similar in both groups (8.6% in Afro-Caribbeans, 9.2% in non-Hispanic whites; P = 0.60). A multivariate analysis also found no difference in the occurrence of adenomas (P = 0.60) or advanced adenomas (P = 0.99) between Afro-Caribbeans and non-Hispanic whites. Conclusions We found a similar adenoma detection rate and advanced adenoma prevalence among Afro-Caribbeans and non-Hispanic whites undergoing their first screening colonoscopy. As such, the Afro-Caribbean population may not have the same risk of colorectal neoplasia as what has been described for African Americans. Based on these results, it is appropriate to initiate colorectal cancer screening for Afro-Caribbeans at age 50 as recommended for non-Hispanic whites.

Can polyp detection rate be used prospectively as a marker of adenoma detection rate

BackgroundAdenoma detection rate (ADR) is a quality indicator for screening colonoscopy, but its calculation is time-consuming. Polyp detection rate (PDR) has been found to correlate with ADR; however, its use as a quality indicator has been criticized out of concern for endoscopists artificially inflating the PDR. We aim to evaluate whether active monitoring affects PDR.MethodsIn March 2015, 14 endoscopists were made aware that their personal PDRs would be tracked monthly as a quality improvement project. Endoscopists received a report of their individual monthly and cumulative PDR, departmental averages, and a benchmark PDR. Following the intervention, data were collected for consecutive patients undergoing average risk screening colonoscopy for six months. PDR, ADR, and adenoma to polyp detection ratio quotient (APDRQ) were compared to a six-month pre-intervention period.Results2203 patients were included in the study. There was no statistically significant difference in PDR when comparing pre- and post-intervention (44 vs. 45%, OR 1.04; 95% CI 0.77–1.36). No statistically significant difference in ADR was observed when comparing pre- and post-intervention (29 vs. 30%, OR 1.03; 95% CI 0.64–1.52). There was no statistically significant difference in APDRQ when comparing pre- and post-intervention (0.67 vs. 0.66, OR 0.99; 95% CI 0.69–1.33).ConclusionsMonthly report cards did not result in a change in PDR or APDRQ. In some environments, PDR can be used as a surrogate marker of ADR, despite endoscopist awareness that PDR is being measured.

A Unique Case of Noncirrhotic Portal Hypertension Secondary to Extrahepatic Sarcoidosis.

poietins and their tyrosine kinase receptor (Tie-2) in tissue containing angiodysplasia. The investigators therefore concluded that this is early evidence for anomalous angiogenesis as the etiology for the development of GIAD.1 Von Willebrand Factor (vWF) is a multimeric glycoprotein that mediates platelet adhesion to both the subendothelial matrix as well as endothelial surfaces, and acts as a carrier for factor VIII in the circulation. There is evidence to suggest that vWF may play a role in angiogenesis via vascular endothelial growth factor receptor-2 (VEGFR2).2 VEGF is perhaps the most highly recognized proangiogenic protein that plays a crucial role in the early phases of angiogenesis.2 The system of angiopoietins, namely Ang-1 and Ang-2, and the Tie-2 receptor are similarly known for regulating the later phases of angiogenesis, specifically the maturation and stability of newly formed blood vessels.2 Ang-2 antagonistically binds to the Tie-2 receptor as a competitive inhibitor of Ang-1 to prime the vascular endothelium for activation and destabilization, and in doing so, acts synergistically with VEGF to promote angiogenesis.2,3 Starke et al4 have demonstrated that blocking vWF function increases the release of Ang-2 from intracellular stores both in vitro as well in a chimeric model. Furthermore, the integrin avb3 is the most well-known endothelial cell receptor for vWF and has been characterized as having both proangiogenic as well as antiangiogenic functions.2 There is evidence to show that avb3 levels, function, and trafficking are decreased in vWF-deficient endothelial cells, which has also been associated with increased levels of VEGFR2-dependent angiogenesis.5 vWF deficiency has also been related to bleeding GIAD in the setting of aortic stenosis, commonly known as Heyde Syndrome.6 The shear stress from blood flow through a stenotic aortic valve causes unfolding of the globular high molecular weight von Willebrand multimers (HMWM) into a linear conformation. This in turn renders the HMWM susceptible to cleavage from a proteolytic enzyme, ADAMTS-13. In addition, GIAD have been associated with the loss of HMWM particularly in type 2 and type 3 von Willebrand disease.2 Although there is evidence to show there is no difference in vWF levels between patients with GIAD and controls,7 vWF deficiency or loss of HMWM may be transient in nature and therefore quantitative measurement of these factors is potentially unreliable. It seems that a lack of vWF may cause the release of other angiogenic factors, such as Ang-2, which stimulates VEGF production, and ultimately promotes angiogenesis. VEGF has also been found to be expressed on colonic GIAD and has therefore been a target of therapy for GIAD.8,9 Future studies are needed to evaluate the relationship between vWF deficiency and Ang-2 in humans to elucidate potential therapies for bleeding GIAD.

PTU-011 Impact of weight loss after bariatric surgery on adenoma detection rate in colonoscopy: a case control study

Introduction Studies have determined that a high Body Mass Index (BMI) is associated with an increased risk of colonic adenoma. There is a paucity of data on the impact of weight loss in morbidly obese populations and its effects on colonic adenoma detection rate (ADR). This study aimed to determine the impact of weight loss after bariatric surgery on the adenoma detection rate on colonoscopy. Method After IRB approval a retrospective review of prospectively collected data was performed for patients who underwent bariatric surgery between 2004–2012. Patients who had a colonoscopy after bariatric surgery were identified as cases. Controls included a random sample of patients who had a colonoscopy during the same timeperiod. They were matched by age and gender in 1:4 ratio of case to controls. Patients with poor bowel preparation or Ottawa score >11 were excluded. Patient demographics, baseline BMI and BMI at colonoscopy, weight change, co-morbidities, type of bariatric surgery and presence/absence of adenoma or advanced adenoma (AA) were collected. Adenoma and AA detection rates were analysed by age (<40; 40–49; 50–59; >60 years) and compared between the two groups. AA was defined as tubular adenoma or serrated polyp ≥10 mm in diameter, villous features, high-grade dysplasia. Hyperplastic polyps ≥10 mm were classified as advanced adenoma. Results 194 cases and 797 controls were included (females 68%). The mean age of patients was 51.5 years. 62.3% of the patients underwent gastric bypass, 28.5% sleeve gastrectomy and 9.2% gastric band. Average decrease in BMI after bariatric surgery was 13 ± 5.5 kg/m2. The median follow-up was 31.6 (2–107) months. The average BMI at the time of colonoscopy of the cases and controls was 32 ± 6 kg/m2and 27.4 ± 5.5 kg/m2respectively. There was no significant difference in adenoma and AA detection rate between groups analysed by age. Among those who underwent bariatric surgery, there was no relation between the occurrence of adenomas and BMI reduction; however the effect of BMI reduction on the occurrence of AA did approach significance. (P = 0.05). The time interval between bariatric surgery and colonoscopy was not related to the incidence of adenoma nor AA. Conclusion Despite the differences in BMI between the patients and controls we found no difference in adenoma or advanced adenoma detection. BMI reduction after bariatric surgery did not affect the presence of adenomas but may be associated with a significant decrease in the risk of developing AA. Further studies with large population data might be required to validate these findings. Disclosure of interest None Declared.