Robert H. Lee

Quality of colonoscopy withdrawal technique and variability in adenoma detection rates (with videos)

BACKGROUND Studies suggest that endoscopist-related factors such as colonoscopy withdrawal time are important in determining the adenoma detection rate (ADR). OBJECTIVE To determine the importance of withdrawal technique in differentiating among endoscopists with varying ADRs. DESIGN Prospective, multicenter study. SETTING Five academic tertiary-care medical centers. PARTICIPANTS This study involved 11 gastroenterology faculty endoscopists. INTERVENTION A retrospective review of screening colonoscopies was performed to categorize endoscopists into low, moderate, and high ADR groups. Video recordings were randomly obtained for each endoscopist on 20 (10 real, 10 sham) withdrawals during colonoscopies performed for average-risk colorectal cancer screening. Three blinded reviewers assigned withdrawal technique scores (total of 75 points) on 110 video recordings. A separate reviewer recorded withdrawal times. MAIN OUTCOME MEASUREMENTS Withdrawal technique scores and withdrawal times. RESULTS Mean (± standard deviation [SD]) withdrawal technique scores were higher in the moderate (62 ± 2.5) and high (59.5 ± 3) ADR groups compared with the low (40.8±3) ADR group (P = .002). Mean (± SD) withdrawal times were 6.3 ± 1.8 minutes (low ADR), 10.2 ± 1.5 minutes (moderate ADR), and 8.2 ± 1.8 minutes (high ADR) (P = .29). A comparison of the withdrawal times and technique scores of the two individual endoscopists with the lowest and highest ADRs did not find a significant difference in withdrawal times (6.6 ± 1.7 vs 7.4 ± 1.7 minutes) (P = .36) but did find a nearly 2-fold difference in technique scores (36.2 ± 9 vs 62.8 ± 9.9) (P = .0001). LIMITATIONS Not adequately powered to detect small differences in withdrawal times. CONCLUSION Withdrawal technique is an important indicator that differentiates between endoscopists with varying ADRs. It is possible that withdrawal technique is equal to, if not more important than, withdrawal time in determining ADRs.

Use of the Endocuff during routine colonoscopy examination improves adenoma detection: A meta-analysis

AIM To perform meta-analysis of the use of Endocuff during average risk screening colonoscopy. METHODS Scopus, Cochrane databases, MEDLINE/PubMed, and CINAHL were searched in April 2016. Abstracts from Digestive Disease Week, United European Gastroenterology, and the American College of Gastroenterology meeting were also searched from 2004-2015. Studies comparing EC-assisted colonoscopy (EAC) to standard colonoscopy, for any indication, were included in the analysis. The analysis was conducted by using the Mantel-Haenszel or DerSimonian and Laird models with the odds ratio (OR) to assess adenoma detection, cecal intubation rate, and complications performed. RESULTS Nine studies (n = 5624 patients) were included in the analysis. Compared to standard colonoscopy, procedures performed with EC had higher frequencies for adenoma (OR = 1.49, 95%CI: 1.23-1.80; P = 0.03), and sessile serrated adenomas detection (OR = 2.34 95%CI: 1.63-3.36; P < 0.001). There was no significant difference in cecal intubation rates between the EAC group and standard colonoscopy (OR = 1.26, 95%CI: 0.70-2.27, I2 = 0%; P = 0.44). EAC was associated with a higher risk of complications, most commonly being superficial mucosal injury without higher frequency for perforation. CONCLUSION The use of an EC on colonoscopy appears to improve pre-cancerous polyp detection without any difference in cecal intubation rates compared to standard colonoscopy.

Quality colonoscopy: A matter of time, technique or technology?

Quality colonoscopy is defined by the detection of adenomatous polyps at least 25% of the time in men and 15% of the time in women. Recent studies highlight the importance of key aspects of high quality colonoscopy. These include the amount of time spent examining the mucosa or withdrawal time, the quality of withdrawal technique and new technologies which seek to maximize the detection of colonic neoplasia. This review summarizes the latest evidence regarding the role of time, technique and technology in shaping the quality of colonoscopy.

Su2026 PPI Use and Small Intestinal Bacterial Overgrowth Detected on Lactulose Breath Testing: Results of a Prospective Cross Sectional Study Among U.S. Veterans With Irritable Bowel Syndrome

Background/Aims: Proton Pump Inhibitors (PPIs) have been proposed to be the missing link in the controversy surrounding Small Intestinal Bacterial Overgrowth (SIBO) and Irritable Bowel Syndrome (IBS). Recent studies examining the relationship between PPIs and SIBO have been limited by retrospective analysis and failure to control for confounding factors such as somatization which may be common to both PPI use and SIBO. Consequently, the aims of this prospective cross sectional study were: 1) To calculate adjusted Odds Ratios (ORs) for hydrogen (H2) and methane (CH4) SIBO based upon PPI use 2) To determine the impact of PPI use on Lactulose Breath Testing (LBT) parameters. Methods: 149 nondiabetic veterans (67 PPI users, 82 non-users, 82% male, mean age 45) meeting Rome III IBS criteria undergoing LBT were recruited. Data on IBS subtype and severity (IBS Severity Scoring System), bloating, depression/anxiety (Hospital Anxiety Depression Score) and somatization (Psychosomatic Symptom Checklist) were obtained by questionnaire. Use of PPIs, fiber, laxatives, probiotics, H2-Blockers, anti-cholinergics, diagnoses of GERD and BMI were obtained from the medical record. LBTs were defined as positive using different criteria: 1) Two H2 Peaks (Increase .20 ppm over the baseline by 90 min with a single peak occurring at least 15 min prior to the second peak with a trough after the first peak of . 5ppm) 2) Increase in H2 by . 20 ppm by 90 min. 3) Any CH4 . 5 ppm 4) Rise in CH4 by. 20 ppm by 90 min. Adjusting for confounding factors using logistic regression, adjusted ORs for PPI use and SIBO were calculated. LBT parameters including baseline H2 and CH4, amplitude of rise to first H2 peak (P1), and time to P1 were compared between PPI and non-PPI groups using Wilcoxon rank sum and t-tests. Results: The prevalence of H2-SIBO using Two H2 Peak criteria was 36.9% in PPI vs. 17.9% in Non-PPI groups (p=0.01). Adjusted OR for PPI Use and Two Peak H2-SIBO was 4.3 (95% CI 1.4-12.9, p=0.01). PPI use of . 180 days was found to be associated with Two Peak H2-SIBO with OR 3.2 (95% CI 1.2-8.9, p=0.02). ORs for PPI use and SIBO were not statistically significant using the other H2 or CH4 criteria (Table). Among LBT parameters, there was a trend towards a shorter time to P1 in the PPI group (Fig 1). However, a statistically significant difference was found in time to P1 when comparing PPI use of .180 days vs. , 180 days (58.7 vs. 75.7 min, p=0.02) (Fig 1). Comparisons between PPI vs. Non-PPI groups did not find differences in baseline H2 (0 vs. 0 ppm, p=0.45), CH4 (1 vs.1.2 ppm, p=0.70) or amplitude to P1 (50 vs. 45 ppm, p=0.55). Conclusions: PPI use is associated with an increased prevalence of H2-SIBO on LBT but only when using the Two H2 Peak criteria. This may be caused by an earlier rise in H2 in the proximal small bowel seen with prolonged PPI use. (Table) Adjusted Odds Ratios for PPI Use and SIBO Using Different H2 and CH4 Criteria

Esophageal Submucosal Injection of Capsaicin but Not Acid Induces Symptoms in Normal Subjects

Background/Aims Transient receptor potential vanilloid-1 (TRPV1) is a candidate for mediating acid-induced symptoms in the esophagus. We conducted studies to determine if the presence of acid in the mucosa/submucosa and direct activation of TRPV1 by capsaicin elicited symptoms in normal healthy subjects. We also studied the presence of TRPV1 receptors in the esophagus. Methods Unsedated endoscopy was performed on healthy subjects with no symptoms. Using a sclerotherapy needle, normal saline (pH 2.0–7.5) was injected into the mucosa/submucosa, 5 cm above the Z line. In a separate group of healthy subjects, injection of capsaicin and vehicle was also studied. Quality of symptoms was reported using the McGill Pain Questionnaire, and symptom intensity using the visual analogue scale (VAS). Immunohistochemistry was performed on 8 surgical esophagus specimens using TRPV1 antibody. Results Acid injection either did not elicit or elicited mild symptoms in subjects at all pH solutions. Capsaicin but not the vehicle elicited severe heartburn/chest pain in all subjects. Mean VAS for capsaicin was 91 ± 3 and symptoms lasted for 25 ± 1 minutes. Immunohistochemistry revealed a linear TRPV1 staining pattern between the epithelial layer and the submucosa that extended into the papillae. Eighty-five percent of papillae stained positive for TRPV1 with a mean 1.1 positive papillae per high-powered field. Conclusions The mechanism of acid-induced heartburn and chest pain is not the simple interaction of hydrogen ions with afferents located in the esophageal mucosa and submucosa. TRPV1 receptors are present in the lamina propria and their activation induces heartburn and chest pain.