Maged K. Rizk

Quality Indicators for Colonoscopy

Colonoscopy is widely used for the diagnosis and treatment of colonic disorders. Properly performed, colonoscopy is generally safe, accurate, and well tolerated by most patients. Visualization of the mucosa of the entire large intestine and distal terminal ileum is usually possible at colonoscopy. In patients with chronic diarrhea, biopsy specimens can help diagnose the underlying condition. Polyps can be identified and removed during colonoscopy, thereby reducing the risk of colon cancer. Colonoscopy is the preferred method to evaluate the colon in most adult patients with bowel symptoms, iron deficiency anemia, abnormal radiographic studies of the colon, positive colorectal cancer screening tests, postpolypectomy and postcancer resection surveillance, surveillance in inflammatory bowel disease, and in those with suspected masses. The use of colonoscopy has become accepted as the most effective method of screening the colon for neoplasia in patients over the age of 50 years and in younger patients at increased risk (1). The effectiveness of colonoscopy in reducing colon cancer incidence depends on adequate visualization of the entire colon, diligence in examining the mucosa, and patient acceptance of the procedure. Preparation quality affects the ability to perform a complete examination, the duration the procedure, and the need to cancel or reschedule procedures (2, 3). Ineffective preparation is a major contributor to costs (4). Longer withdrawal times have been demonstrated to improve polyp detection rates, (5‐7) and conversely, rapid withdrawal may miss lesions and reduce the effectiveness of colon cancer prevention by colonoscopy. The miss rates of colonoscopy for large (≥1 cm) adenomas may be higher than previously thought (8, 9) Thus, careful examinations are necessary to optimize the effectiveness of recommended intervals between screening and surveillance examinations. Finally, technical expertise will help prevent complications that can offset any cost benefit ratio gained by removing neoplastic lesions. The following quality indicators have been selected to establish competence in performing colonoscopy and help define areas for continuous quality improvement. The levels of evidence supporting these quality indicators were graded according to Table 1. PREPROCEDURE The preprocedure period encompasses the time from first contact by the patient until administration of sedation or instrument insertion. The aspects of patient care addressed in prior documents apply here as well, including timely scheduling, patient preparation, identification, history and physical examination, appropriate choice of sedation and analgesia, evaluation of bleeding risk, etc. Because many examinations are currently being performed for colon cancer screening and are elective, care must be taken to be certain that all potential risks have been reduced to as low as practically achievable. The American Society for Gastrointestinal Endoscopy (ASGE) (10) and the U.S. Multi-Society Task Force on Colon Cancer have published appropriate indications for colonoscopy (11) (Tables 2 and 3).

Quality Indicators for ERCP

ERCP is one of the most technically demanding and high-risk procedures performed by GI endoscopists. It requires significant focused training and experience to maximize success and to minimize poor outcomes (1, 2). ERCP has evolved from a purely diagnostic to a predominately therapeutic procedure (3). ERCP and ancillary interventions are effective in the non-surgical management of a variety of pancreaticobiliary disorders, most commonly the removal of bile duct stones and relief of malignant obstructive jaundice (4). The American Society for Gastrointestinal Endoscopy (ASGE) has published specific criteria for training and granting of clinical privileges for ERCP, which detail the many skills that must be developed to perform this procedure in clinical practice with high quality (5, 6, 7).

Randomized study comparing endoscopic ultrasound-guided Trucut biopsy and fine needle aspiration with high suction

H. Gerke, M. K. Rizk, A. D. Vanderheyden and C. S. Jensen
Randomized study comparing endoscopic ultrasound‐guided Trucut biopsy and fine needle aspiration with high suction

Quality Indicators Common to All GI Endoscopic Procedures

Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (1). The American Society for Gastrointestinal Endoscopy (ASGE), the American College of Gastroenterology (ACG), and the American Gastroenterological Association (AGA) have continually promoted the ideal that all patients have access to high-quality GI endoscopy services. A high-quality endoscopy is an examination in which patients receive an indicated procedure, correct and relevant diagnoses are recognized or excluded, any therapy provided is appropriate, and all steps that minimize risk have been taken.

Hospital readmissions in patients with inflammatory bowel disease

OBJECTIVES:We aimed to identify the frequency and costs of, and the disease predictors and inpatient process issues that may predispose to, 30-day readmission for an inflammatory bowel disease (IBD) patient.METHODS:IBD patients admitted to an inpatient gastroenterology service were followed for a time-to-readmission analysis assessing factors associated with readmission within 30 days.RESULTS:Index admissions were more costly among those readmitted than among those not readmitted. Patients admitted with evidence of increased inflammation, infection, or obstruction or for dehydration or pain control had a higher risk of readmission. Patients treated with opioid analgesia during index admission were no less likely to be readmitted, and there was a 2.2-fold increase in readmissions when patients were discharged with no opioid analgesia. Scheduling variability and outpatient follow-up compliance were associated with readmission.CONCLUSIONS:Predicting readmission is complex. A predictive model developed to be used at discharge yielded an area under the curve of 0.757.

Quality Indicators for EUS

EUS has become integral to the diagnosis and staging of GI and mediastinal mass lesions and conditions. EUS-guided FNA (EUS-FNA) allows the endoscopist to obtain tissue or fluid for cytologic and chemical analysis, adding to the procedures utility. Furthermore, the recent development of EUS-guided core biopsy techniques enables his-tologic sampling in selected cases and for obtaining tissue for molecular analysis in neoadjuvant and palliative settings. The clinical effectiveness of EUS and EUS-FNA depends on the judicious use of these techniques.

Quality indicators for EGD.

Abbreviations: ACG, American College of Gastroenterology; ASGE, American Society for Gastrointestinal Endoscopy; BE, Barrett’s esophagus; ESD, endoscopic submucosal dissection; PPI, proton pump inhibitor

Random biopsies during surveillance colonoscopy increase dysplasia detection in patients with primary sclerosing cholangitis and ulcerative colitis

BACKGROUND AND AIM Patients with primary sclerosing cholangitis (PSC) and ulcerative colitis (UC) are at increased risk of colon dysplasia. The role of random vs. target biopsies in these patients has not been investigated. Our aim was to evaluate the yield and clinical impact of random biopsies during surveillance colonoscopies in patients with PSC-UC. METHODS Data from 71 patients (267 colonoscopies) with PSC and UC, who underwent surveillance colonoscopies and followed-up from 2001 to 2011 was obtained. Colonoscopy and pathology reports were reviewed to assess the yield of random biopsies. RESULTS A total of 3975 (median 12) random biopsies were taken during surveillance colonoscopies. Overall, neoplasia was detected in 22 colonoscopies (16 patients): in 8 colonoscopies (36.4%) by targeted biopsies only and in 4 (18.2%) by both targeted and random biopsies. Neoplasia was detected in random biopsies only in 10 (45.5%) colonoscopies in 8 patients. On multivariate analysis, duration of UC (Odds ratio [OR]=1.40; 95% confidence interval [CI], 1.08-1.81; P=0.01), number of random biopsies (per increase by 8) (OR=1.64; 95% CI, 1.18-2.28; P=0.003) and target biopsies during colonoscopy (OR=9.08; 95% CI, 3.18-26.0; P<0.001) independently predicted the presence of dysplasia; endoscopic features of prior inflammation did not. CONCLUSIONS Random biopsies significantly increase the yield of dysplasia in patients with PSC and UC even in the absence of endoscopic features of prior inflammation and significantly impact clinical outcomes.

Differential Epidural Block Predicts the Success of Visceral Block in Patients with Chronic Visceral Abdominal Pain

Abstract:  Background and Aims:  Differential thoracic epidural regional block, also known as a differential neural block (DNB), involves the placement of an epidural catheter placed in the thoracic epidural space to achieve appropriate anesthesia in a dermatomal distribution. This is a retrospective case series evaluating how well a DNB may predict success of subsequent visceral blockade in patients with chronic abdominal pain of visceral origin.

The value of touch imprint cytology in EUS-guided Trucut biopsy

BACKGROUND EUS-guided Trucut biopsy (TCB) enables the acquisition of tissue cores for histologic assessment. Touch imprint cytology (TIC) can be performed at the time of a biopsy to assess the adequacy of the sample; however, limited information is available on the diagnostic value of TIC of these specimens. OBJECTIVE To investigate the diagnostic accuracy of TIC compared with a TCB. PATIENTS AND DESIGN Consecutive EUS-guided TCB and TIC (n = 109) were retrospectively and independently reviewed by a surgical pathologist (for the TCB) and a cytopathologist (for TIC) blinded to the final diagnoses. SETTING University of Iowa Hospitals and Clinics, Iowa. MAIN OUTCOME MEASUREMENTS Diagnostic accuracy of a TCB, TIC, and combined TCB + TIC. RESULTS The diagnostic accuracy of a TCB was 92.7% (95% CI, 83.1%-97.3%), TIC was 82.6% (95% CI, 74.3%-88.6%), and TCB + TIC was 95.4% (95% CI, of 89.4%-98.3%). The diagnostic accuracy of a TCB alone was superior to TIC alone (P = .038); a TCB was diagnostic in 14 cases that were nondiagnostic by TIC. The addition of TIC allowed for the identification of 3 malignancies (2.8%) that were not identified on TCB alone. In 22 cases, TIC was considered diagnostic, but a TCB provided additional specific diagnostic information. LIMITATIONS Retrospective study and relatively low numbers. CONCLUSIONS TIC is a valuable tool for use in a EUS-guided TCB; TIC is independently diagnostically accurate, which allows for confidence in a rapid preliminary diagnosis, and it provides additional diagnostic value when combined with TCB.