Prashanthi N. Thota

Adenomas Are Detected More Often in Morning Than in Afternoon Colonoscopy

OBJECTIVES:The effectiveness of colonoscopy in preventing colon cancer depends on adenoma detection and removal. Adequacy of bowel preparation, careful mucosal visualization, and adequate withdrawal time are known to affect adenoma detection rate (ADR). Physician fatigue, which usually increases as the day progresses, might impair ADR. The aim of this study is to assess the effect of timing of colonoscopy, morning vs. afternoon, on ADR.METHODS:Medical records of 9,063 colonoscopies performed in 2006 were reviewed for patient demographics, indications, timing, and findings of colonoscopy. Asymptomatic outpatients who had adequate bowel preparation and complete colonoscopy were included. Morning colonoscopies were defined as those that started before 12 noon and afternoon colonoscopies as those that started after 12 noon. ADR is defined as the detection of at least one adenoma per colonoscopy.RESULTS:A total of 3,619 colonoscopies were included, of which 1,748 (48.3%) were done in the morning and 1,871 (51.7%) were done in the afternoon. ADR was 29.3% in the morning group compared with 25.3% in the afternoon group (P=0.008). There was a trend toward declining ADR for each subsequent hour of the day (P=0.01). In multivariable analysis, colonoscopy in the morning was significantly associated with increased ADR (odds ratio (OR) 1.2 (1.06, 1.4) P=0.006).CONCLUSIONS:Time of performance of colonoscopy seems to be an independent predictor for adenoma detection. ADR was significantly higher in morning colonoscopies than in afternoon colonoscopies. The reasons and implications of this finding should be studied further.

Barrett’s Esophagus in Women: Demographic Features and Progression to High-Grade Dysplasia and Cancer

BACKGROUND & AIMS Barretts esophagus is traditionally considered a disease of older white men. The aims of this study were to compare the demographic features of Barretts esophagus in men and women and to determine the prevalence and incidence of high-grade dysplasia and cancer in these patients. METHODS All patients enrolled in the Cleveland Clinic Barretts Esophagus Registry from 1979-2002 were studied. Age, ethnicity, number of endoscopies, hiatal hernia size, length of Barretts segment, and prevalence and incidence of high-grade dysplasia and cancer were compared between men and women. RESULTS There were 839 patients in the registry (628 men and 211 women). Barretts segment length was greater in men than in women (mean, 5.06 +/- 4.2 vs 4.05 +/- 3.27 cm, respectively; P = .003). There were no significant differences for other parameters. There were 114 prevalence cases of high-grade dysplasia or cancer (96 men, 18 women). Women were less likely to have prevalent high-grade dysplasia or cancer than men (odds ratio, 0.52; 95% confidence interval, 0.31-0.88; P = .015). There were 13 incidence cases of high-grade dysplasia or cancer (11 men, 2 women) during a mean follow-up of 4.72 years, which was similar in both genders with an incidence rate of 1 in 179 patient-years of follow-up for women and 1 in 91 patient-years of follow-up in men. CONCLUSIONS Twenty-five percent of patients in our registry are women. The length of Barretts esophagus is greater in men than in women, but other features are similar. The prevalence of high-grade dysplasia/cancer in women is approximately half that of men. Incidence rates for high-grade dysplasia/cancer are similar in men and women, although the number of cases is small.

Long-term esophageal and respiratory outcomes in children with esophageal atresia and tracheoesophageal fistula.

Objectives: Few studies have evaluated the long-term complications and outcomes of esophageal atresia with or without tracheoesophageal fistula (EA/TEF) beyond childhood. The aim of our study was to characterize the esophageal and respiratory morbidity of EA/TEF through evaluation of clinical symptoms, diagnostic testing and therapeutic intervention at a tertiary care center. Methods: Patients with congenital EA/TEF evaluated from 2011 to 2014 were included. Demographic characteristics, type and mode of repair of EA/TEF, clinical symptoms, radiographic, endoscopic, bronchoscopic and medication use data were obtained. Results: A total of 43 patients were identified. The median age of this predominantly Caucasian population was 8 years (interquartile range: 3, 20). Twenty (62.5%) had type C (EA with distal TEF) abnormality. Twenty-one (48.8%) patients had heartburn, 19 (44.1%) had acid regurgitation, and 31 (72.1%) had dysphagia to solids. Barium swallow in 26 patients revealed strictures in 17 (65.4%), dysmotility in 20 (76.9%) and recurrent fistulas in four patients (15.4%). Thirty patients underwent upper endoscopy, of which 21 (70.0%) had a stricture, and six (20.0%) had recurrent fistula requiring surgical intervention. Eight (18.6%) patients underwent fundoplication. Pulmonary evaluation showed cough and choking in 31 (72.1%) patients and dyspnea and wheezing in 32 (53.4%) patients. Recurrent respiratory infections were reported in 19 (44.2%).patients. Other findings included tracheomalacia in 86.7% and restrictive lung disease in 54.5% of patients. Conclusion: There is a high burden of residual esophageal and pulmonary pathology in patients with EA/TEF. Ongoing follow-up is required to monitor both the clinical symptoms and treatment responses.

Adenoma and sessile serrated polyp detection rates: variation by patient sex and colonic segment but not specialty of the endoscopist.

BACKGROUND: Adenoma detection rate is an important quality indicator. High adenoma detection rate is related to fewer interval cancers. Interval cancers arise from sessile serrated polyps, often in the proximal colon. The detection of adenomas and sessile serrated polyps by location may enhance colonoscopy efficacy. OBJECTIVE: The aim of this study was to determine entire colon and segmental adenoma and sessile serrated polyp detection rates and to assess the impact of endoscopist specialty on polyp detection. DESIGN: Colonoscopies performed by 65 multispecialty endoscopists were studied. SETTING: This study was conducted at an academic medical center. PATIENTS: Average-risk outpatients undergoing screening colonoscopy were selected. MAIN OUTCOME MEASURES: Polyp detection rates were determined by sex, colon segment, and each endoscopist. RESULTS: Included were 2167 patients. Adenoma and sessile serrated polyp detection rates were 25% and 2% and not significantly different by specialty of the endoscopist. The adenoma detection rate was higher in men (31%) than in women (20%), including each segment in the colon. It was higher proximally (20%) than distally (16%) (p = 0.027) in men, but no different in proximal (11%) and distal colon (11%) (p = 0.66) in women. Sessile serrated polyp detection was the same in men and women at 2% (p = 0.84) and 3-fold higher in the proximal than in the distal colon (1.4% vs 0.5%), but only significantly so in women (p = 0.041). We found a poor correlation between adenoma and sessile serrated polyp detection rates (r = 0.35). LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: Prevalent adenomas are detected more often in men than in women, including overall and by colon segment. The proximal adenoma detection rate is significantly higher than the distal adenoma detection rate in men, but segmental rates are similar in women. Sessile serrated polyp detection rates are low, albeit 3-fold higher in the proximal colon, and are found as frequently in men and women. High-quality colonoscopy, as evidenced by adenoma detection rate, varies by endoscopist but is independent of colonoscopist subspecialty.

Polypectomy Rate: A Surrogate for Adenoma Detection Rate Varies by Colon Segment, Gender, and Endoscopist

BACKGROUND & AIMS The adenoma detection rate (ADR) is an important measure of the quality of colonoscopy; it is associated with interval colorectal cancer and varies among sexes and locations. Recommended indicators of competence for colonoscopy include minimal ADRs >25% for average-risk men and >15% for women. These ADRs are rigorous, so polypectomy detection rate (PR) has been suggested as a surrogate. Colonoscopy is less effective in the proximal colon, where interval cancers are more likely to occur. We compared ADRs and PRs in different segments of colon and between sexes. METHODS We performed a cross-sectional review of findings from 2167 screening colonoscopies performed by 65 endoscopists on average-risk outpatients at the Cleveland Clinic, 2008-2009. We reviewed colonoscopy and pathology reports of randomly selected procedures (mean, 33 ± 16 procedures per endoscopist). We calculated PRs, ADRs, and correlation between PR and ADR for each colon segment and sex. RESULTS The mean overall PR was 42% ± 16.7%, and ADR was 25% ± 3.3%. The correlation between overall ADR and PR was strong (r = 0.80). PR of 40% in men and 30% in women correlated with the established minimum benchmark ADRs of 25% and 15% for men and women, respectively. PR was more strongly correlated with ADR in the proximal colon (r = 0.92) than the distal colon (r = 0.58). The correlation was stronger in men than in women, as well as in the entire colon (r = 0.88 vs 0.75), the proximal colon (r = 0.91 vs 0.87), and the distal colon (r = 0.75 vs 0.55). The advanced ADR was 4% and did not correlate with PR (r = 0.32). CONCLUSIONS On the basis of a review of findings from screening colonoscopies, overall PR correlates with ADR for the entire colon, but PR and ADR correlate most strongly for the proximal colon, where many adenomas can be missed and interval cancers develop. The correlation between PR and ADR is weaker for women than men and for distal colon. If PR is used as a surrogate for ADR, colon location and patient sex should be considered.

Risk for esophageal neoplasia in Barrett's esophagus patients with mucosal changes indefinite for dysplasia.

Patients with Barretts esophagus (BE) are at increased risk for esophageal adenocarcinoma (EAC) and therefore require surveillance. Biopsies are classified as indefinite for dysplasia (IND) when the significance of epithelial abnormalities is uncertain due to inflammation or sampling. Our aim was to characterize the neoplastic risk of IND in BE patients and to identify predictors of neoplastic risk.

Relationship between type-2 diabetes and use of metformin with risk of colorectal adenoma in an American population receiving colonoscopy

The aim of this study is to explore the relationship between type-2 diabetes, its treatments (Use of metformin) and the development of colorectal adenoma. Colonoscopy reports from a total of 66 endoscopists in one big hospital in midwest during 2008-2009 were reviewed. Colonoscopy findings including quality of preparation, polyp size, location, morphology, pathology and history of diabetes and metformin treatment were retrieved. Of the 7382 colonoscopy reports were reviewed, 3465 average risk patients were included in our final analysis. The pathologically proven Adenoma detection rate (ADR) in total population was 24.6 % (30.2% in Men and 19.2% in Women). Old age and male sex were significantly associated with increasing risk of colorectal adenoma. Type-2 diabetes was associated increased risk of colorectal adenoma (OD 1.35, 95% confidence interval 1.08-1.70, p=0.009). A total of 426 subjects (12.29%) had diabetes and 405 of these subjects (11.7%) had type-2 diabetes. Within diabetic patient group, people who were taking metformin have significantly lower risk of colorectal adenoma (OD 0.55, 95% confidence interval 0.34-0.87, p=0.011). Diabetic subjects have increased risk of developing colorectal adenoma. Our study also supports the beneficial effect of metformin in development of colorectal adenoma.

Timed barium esophagram in achalasia types

Relationships of timed barium esophagram (TBE) findings to achalasia types defined by high-resolution manometry (HRM) have not been elucidated. Therefore, we correlated preoperative TBE and HRM measurements in achalasia types and related these to patient symptoms and prior treatments. From 2006 to 2013, 248 achalasia patients underwent TBE and HRM before Heller myotomy. TBE height and width were recorded at 1 and 5 minutes; HRM measured lower esophageal sphincter mean basal pressure, integrated relaxation pressure (IRP), and mean esophageal body contraction amplitude. Achalasia was classified into types I (25%), II (65%), and III (9.7%). TBE height at 5 minutes was higher for I (median 8 cm; interquartile range 6-12) and II (8 cm; 8-11) than for III (1 cm; 0-7). TBE width at 5 minutes was widest (3 cm; 2-4), narrower in II (2 cm; 2-3), and narrowest in I (1 cm; 0-2), P < 0.001. Volume remaining at 1 and 5 minutes was lower in III (1 m(2) ; 0-16) than I (42 m(2) ; 17-106) and II (39 m(2) ; 15-60), highlighting poorer emptying of I and II. Increasing TBE width correlated with deteriorating morphology and function from III to II to I. Symptoms poorly correlated with TBE and HRM. Prior treatment was associated with less regurgitation, faster emptying, and lower IRP. Although TBE and HRM are correlated in many respects, the wide range of their measurements observed in this study reveals a spectrum of morphology and dysfunction in achalasia that is best characterized by the combination of these studies.

Post-ablation lymphocytic esophagitis in Barrett esophagus with high grade dysplasia or intramucosal carcinoma

In patients who have undergone ablation therapy for treatment of Barretts esophagus with dysplasia, histologic features of eosinophilic esophagitis, but not lymphocytic esophagitis, have been described. We evaluated for histologic evidence of eosinophilic esophagitis and lymphocytic esophagitis and correlated with endoscopic findings in this population. A single-institution Barretts esophagus registry was searched for patients who had received radiofrequency ablation, cryotherapy, or both for treatment of Barretts esophagus with dysplasia. Clinical and endoscopic data were collected and biopsies were reviewed for inflammation and reactive changes at three time points: pre-intervention, first surveillance after ablation therapy, and most recent surveillance. Of the 173 patients initially identified, 102 met the inclusion criteria. Intraepithelial eosinophils were increased at first surveillance (60%, P=0.096) and last surveillance (69%, P=0.048) compared with pre-intervention (50%), although histologic evidence of post-ablation eosinophilic esophagitis was not significant. Prevalence of lymphocytic esophagitis was significantly higher at first surveillance (17%, P=0.02) and at last surveillance (43%, P<0.001), compared with pre-intervention (7%). Smoking, hyperlipidemia, and cryotherapy were identified as independent risk factors for developing histologic lymphocytic esophagitis. This is the first report that histologic evidence of lymphocytic esophagitis increased over time in patients undergoing ablation for Barretts esophagus with dysplasia. Though the pathophysiology of lymphocytic esophagitis remains unknown, patients in our study with a history of smoking, hyperlipidemia, or cryotherapy were more likely to develop post-ablation lymphocytic esophagitis.

Adenoma detection rate in high-risk patients differs from that in average-risk patients

BACKGROUND Adenoma detection rates (ADRs) are established as quality targets in average-risk (AR) individuals undergoing colorectal cancer (CRC) screening colonoscopy. Little is known about the ADR in high-risk (HR) individuals undergoing index or surveillance colonoscopy. OBJECTIVE To determine and compare ADR in HR versus AR individuals undergoing colonoscopy. DESIGN AND SETTING Retrospective study, tertiary care center. PATIENTS AND INTERVENTION We reviewed records of 7357 patients who underwent colonoscopy by 66 multispecialty endoscopists at our institution during the period 2008 to 2009. Both screening and surveillance colonoscopies in AR and HR patients for CRC were studied. HR patients were further divided into 3 subgroups: those with a (1) personal history of polyps (PHP), (2) family history of polyps (FHP), and (3) family history of CRC (FHCRC). Multivariable logistic regression analysis was performed to evaluate differences in ADR between the groups after adjusting for possible confounders. MAIN OUTCOME MEASUREMENTS ADR in HR patients. RESULTS The study included 4141 patients, of whom 2170 were AR and 1971 were HR. Patients in the HR group were older (64.5 ± 9.1 years vs 59.1 ± 7.9 years, P < .001). HR patients were more likely to have adenomas (30.7% vs 25.6%, P < .001). Adenomas were detected more often in the proximal colon than in the distal colon (29.3% vs 21.0%, P < .001 and 22.8% vs 15.8%, P < .001, respectively). Patients with a PHP had the highest ADR (33.1%, P < .001). However, after adjusting for confounders, HR status was not found to be associated with ADR (odds ratio [OR] 1.2; 95% confidence interval [CI], 0.93-1.6; P = .15 for females and 0.93; 95% CI, 0.70-1.2; P = .61 for males). HR females were found to have a 40% greater likelihood of having proximal adenomas than AR females (1.4; 95% CI, 1.01-2; P = .04). LIMITATIONS Retrospective design, single tertiary center. CONCLUSIONS Patients with a PHP have a significantly higher ADR compared with AR patients. Defining a minimum target ADR for individuals with a PHP undergoing surveillance colonoscopy is important.