Megan A. Adams

American Gastroenterological Association Institute Guideline on the Diagnosis and Management of Asymptomatic Neoplastic Pancreatic Cysts

This article has an accompanying continuing medical education activity on page e12. Learning Objective: At the conclusion of this exercise, the learner will understand the approach to counseling patients regarding the optimal method and frequency of radiologic imaging, indications for invasive tests like endoscopic ultrasonography (EUS) and surgery, select patients for follow-up after surgery, decide the duration of such follow-up, and decide when to stop surveillance for those with and without surgery.

American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis 67 68 69 70 71 72 73 74 Neil Stollman, Walter Smalley, Ikuo Hirano, and AGA Institute Clinical Guidelines Committee

American Gastroenterological Association Institute Guideline on the Diagnosis and Management of Lynch Syndrome

Veterans Affairs Center for Clinical Management Research; Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan; Division of Gastroenterology, St Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada; Departments of Family Medicine and Urology, University of Michigan Medical School, Ann Arbor, Michigan; and Division of Gastroenterology, McGill University, McGill University Health Centre, Montreal, Quebec, Canada

Evaluation of Pharmacologic Prevention of Pancreatitis After Endoscopic Retrograde Cholangiopancreatography: A Systematic Review

BACKGROUND & AIMS There is controversy over the efficacy of pharmacologic agents for preventing pancreatitis after endoscopic retrograde cholangiopancreatography (PEP). We performed a systematic review of PEP pharmacoprevention to evaluate safety and efficacy. METHODS We performed a systematic search of the literature for randomized controlled trials (RCTs) and meta-analyses of PEP pharmacoprevention through February 2014. After identifying relevant studies, 2 reviewers each extracted information on study characteristics, clinical outcomes, and risk of bias. A research classification scale was developed to identify pharmacologic agents ready for clinical use, agents for which a confirmatory RCT should be considered a high priority, agents for which exploratory studies are still necessary, and agents for which additional research should be of low priority. Clinical and research recommendations for each agent were made by consensus after considering research classification results and other important factors such as magnitude of benefit, safety, availability, and cost. RESULTS After screening 851 citations and 263 potentially relevant articles, 2 reviewers identified 85 RCTs and 28 meta-analyses that were eligible. On the basis of these studies, rectal nonsteroidal anti-inflammatory drugs were found to be appropriate for clinical use, especially for high-risk cases. Sublingual nitroglycerin, bolus-administered somatostatin, and nafamostat were found to be promising agents for which confirmatory research is warranted. Additional research was found to be required to justify confirmatory RCTs for topical epinephrine, aggressive intravenous fluids, gabexate, ulinastatin, secretin, and antibiotics. CONCLUSIONS On the basis of a systematic review, NSAIDs are appropriate for use in prevention of PEP, especially for high-risk cases. Additional research is necessary to clarify the role of other pharmacologic agents. These findings could inform future research and guide clinical decision-making and policy.

Self-expanding metal stents (SEMS) provide superior outcomes compared to plastic stents for pancreatic cancer patients undergoing neoadjuvant therapy

BACKGROUND Neoadjuvant therapy is increasingly utilized for pancreatic cancer patients to decrease tumor burden in anticipation of later surgical resection. However, infectious complications such as life threatening cholangitis may occur for those with biliary obstruction. We hypothesized that placement of metal rather than plastic stents in such patients results in lower rates of stent-related complications, leading to improved clinical outcomes. METHODS Retrospective cohort of pancreatic cancer patients treated by the University of Michigan Multidisciplinary Pancreatic Cancer Destination Program between January 2005 and June 2010. Only patients undergoing neoadjuvant therapy with one or more biliary stents placed for malignant obstruction were studied. Time to stent complication was compared between metal and plastic stents. The complication rate was estimated as the ratio of complications to total stent exposure time and 95% confidence intervals were calculated. RESULTS 52 patients met inclusion criteria. A total of 113 stents were placed in 52 patients (70 plastic, 43 metal). The complication rate was almost 7 times higher with plastic stents, 0.20 (95% CI, 0.14-0.30), than with metal stents, 0.03 (95% CI, 0.01-0.06). Moreover, the rate of hospitalization for stent-related complications was 3-fold higher in the plastic stent group than the metal stent group. The first quartile estimate of time to stent complication was almost 5 times longer for metal than for plastic stents (44 vs. 200 days) (P<0.0001). CONCLUSION Compelling evidence indicates that self-expanding metal, not plastic stents should be used for malignant biliary obstruction in patients undergoing neoadjuvant therapy for pancreatic cancer.

Predicting the likelihood of a persistent bile duct stone in patients with suspected choledocholithiasis: accuracy of existing guidelines and the impact of laboratory trends

BACKGROUND Existing guidelines aim to stratify the likelihood of choledocholithiasis to guide the use of ERCP versus a lower-risk diagnostic study such as EUS, MRCP, or intraoperative cholangiography. OBJECTIVE To assess the performance of existing guidelines in predicting choledocholithiasis and to determine whether trends in laboratory parameters improve diagnostic accuracy. DESIGN Retrospective cohort study. SETTING Tertiary-care hospital. PATIENTS Hospitalized patients presenting with suspected choledocholithiasis over a 6-year period. INTERVENTIONS Assessment of the American Society for Gastrointestinal Endoscopy (ASGE) guidelines, its component variables, and laboratory trends in predicting choledocholithiasis. MAIN OUTCOME MEASUREMENTS The presence of choledocholithiasis confirmed by EUS, MRCP, or ERCP. RESULTS A total of 179 (35.9%) of the 498 eligible patients met ASGE high-probability criteria for choledocholithiasis on initial presentation. Of those, 99 patients (56.3%) had a stone/sludge on subsequent confirmatory test. Of patients not meeting high-probability criteria on presentation, 111 (34.8%) had a stone/sludge. The overall accuracy of the guidelines in detecting choledocholithiasis was 62.1% (47.4% sensitivity, 73% specificity) based on data available at presentation. The accuracy was unchanged when incorporating the second set of liver chemistries obtained after admission (63.2%), suggesting that laboratory trends do not improve performance. LIMITATIONS Retrospective study, inconsistent timing of the second set of biochemical markers. CONCLUSION In our cohort of patients, existing choledocholithiasis guidelines lacked diagnostic accuracy, likely resulting in overuse of ERCP. Incorporation of laboratory trends did not improve performance. Additional research focused on risk stratification is necessary to meet the goal of eliminating unnecessary diagnostic ERCP.

Effect of a Health System's Medical Error Disclosure Program on Gastroenterology-Related Claims Rates and Costs

OBJECTIVES:In 2001, the University of Michigan Health System (UMHS) implemented a novel medical error disclosure program. This study analyzes the effect of this program on gastroenterology (GI)-related claims and costs.METHODS:This was a review of claims in the UMHS Risk Management Database (1990–2010), naming a gastroenterologist. Claims were classified according to pre-determined categories. Claims data, including incident date, date of resolution, and total liability dollars, were reviewed. Mean total liability incurred per claim in the pre- and post-implementation eras was compared. Patient encounter data from the Division of Gastroenterology was also reviewed in order to benchmark claims data with changes in clinical volume.RESULTS:There were 238,911 GI encounters in the pre-implementation era and 411,944 in the post-implementation era. A total of 66 encounters resulted in claims: 38 in the pre-implementation era and 28 in the post-implementation era. Of the total number of claims, 15.2% alleged delay in diagnosis/misdiagnosis, 42.4% related to a procedure, and 42.4% involved improper management, treatment, or monitoring. The reduction in the proportion of encounters resulting in claims was statistically significant (P=0.001), as was the reduction in time to claim resolution (1,000 vs. 460 days) (P<0.0001). There was also a reduction in the mean total liability per claim (

National Trends in Use of Monitored Anesthesia Care for Outpatient Gastrointestinal Endoscopy in the Veterans Health Administration

167,309 pre vs.

Navigating a Successful Course Through GI Fellowship: A Year-by-Year Perspective

81,107 post, 95% confidence interval: 33682.5–300936.2 pre vs. 1687.8–160526.7 post).CONCLUSIONS:Implementation of a novel medical error disclosure program, promoting transparency and quality improvement, not only decreased the number of GI-related claims per patient encounter, but also dramatically shortened the time to claim resolution.

Medical Professional Liability Claims Related to Esophageal Cancer Screening

Author Affiliations: Department of Health Policy and Administration, Pennsylvania State University, University Park (Segel); Penn State Hershey Cancer Institute, Hershey, Pennsylvania (Segel); Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (Kullgren); Department of Internal Medicine, University of Michigan Medical School, Ann Arbor (Kullgren); University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor (Kullgren).