Sravanthi Parasa

Advanced Imaging Technologies Increase Detection of Dysplasia and Neoplasia in Patients With Barrett's Esophagus: A Meta-analysis and Systematic Review

BACKGROUND & AIMS US guidelines recommend surveillance of patients with Barretts esophagus (BE) to detect dysplasia. BE conventionally is monitored via white-light endoscopy (WLE) and a collection of random biopsy specimens. However, this approach does not definitively or consistently detect areas of dysplasia. Advanced imaging technologies can increase the detection of dysplasia and cancer. We investigated whether these imaging technologies can increase the diagnostic yield for the detection of neoplasia in patients with BE, compared with WLE and analysis of random biopsy specimens. METHODS We performed a systematic review, using Medline and Embase, to identify relevant peer-review studies. Fourteen studies were included in the final analysis, with a total of 843 patients. Our metameter (estimate) of interest was the paired-risk difference (RD), defined as the difference in yield of the detection of dysplasia or cancer using advanced imaging vs WLE. The estimated paired-RD and 95% confidence interval (CI) were obtained using random-effects models. Heterogeneity was assessed by means of the Q statistic and the I(2) statistic. An exploratory meta-regression was performed to look for associations between the metameter and potential confounders or modifiers. RESULTS Overall, advanced imaging techniques increased the diagnostic yield for detection of dysplasia or cancer by 34% (95% CI, 20%-56%; P < .0001). A subgroup analysis showed that virtual chromoendoscopy significantly increased the diagnostic yield (RD, 0.34; 95% CI, 0.14-0.56; P < .0001). The RD for chromoendoscopy was 0.35 (95% CI, 0.13-0.56; P = .0001). There was no significant difference between virtual chromoendoscopy and chromoendoscopy, based on Student t test analysis (P = .45). CONCLUSIONS Based on a meta-analysis, advanced imaging techniques such as chromoendoscopy or virtual chromoendoscopy significantly increase the diagnostic yield for identification of dysplasia or cancer in patients with BE.

Inter-Observer Agreement among Pathologists Using Wide-Area Transepithelial Sampling With Computer-Assisted Analysis in Patients With Barrett's Esophagus.

OBJECTIVES:The histopathological diagnosis of Barrett’s esophagus (BE)-associated dysplasia has poor inter-observer agreement. The wide-area transepithelial sampling (WATS) procedure uses a minimally invasive brush biopsy technique for acquiring wide-area sampling of BE tissue followed by computer-assisted analysis. In this study, our aim was to assess inter-observer agreement among pathologists in the diagnosis of Barrett’s-associated dysplasia using the WATS computer-assisted analysis technique.METHODS:WATS slides with varying degrees of BE dysplasia were randomly selected and distributed to four pathologists. Each pathologist graded the slides as nondysplastic, low-grade dysplasia (LGD), or high-grade dysplasia/esophageal adenocarcinoma (HGD/EAC) and completed a standardized case report form (CRF) for each slide.RESULTS:In all, 149 BE slides were evaluated in a blinded manner by 4 pathologists. The slides included the following: no dysplasia (n=109), LGD, and HGD/EAC (n=40). The overall mean kappa value for all 3 diagnoses for the 4 observers was calculated at 0.86 (95% confidence interval (CI) 0.75–0.97). The kappa values (95% CI) for HGD/EAC, IND/LGD, and no dysplasia were 0.95 (0.88–0.99), 0.74 (0.61–0.85), and 0.88 (0.81–0.94), respectively.CONCLUSIONS:The diagnosis of BE and associated dysplasia using the WATS technique has very high inter-observer agreement. This appears to be significantly higher as compared with previously published data using standard histopathology.

Complications of gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GORD) is on the rise with more than 20% of the western population reporting symptoms and is the most common gastrointestinal disorder in the United States. This increase in GORD is not exactly clear but has been attributed to the increasing prevalence of obesity, changing diet, and perhaps the decreasing prevalence of H. pylori infection. Complications of GORD could be either benign or malignant. Benign complications include erosive oesophagitis, bleeding and peptic strictures. Premalignant and malignant lesions include Barretts metaplasia, and oesophageal cancer. Management of both the benign and malignant complications can be challenging. With the use of proton-pump inhibitors, peptic strictures (i.e., strictures related to reflux) have significantly declined. Several aspects of Barretts management remain controversial including the stage in the disease process which needs to be intervened, type of the intervention and surveillance of these lesions to prevent development of high grade dysplasia and oesophageal adenocarcinoma.

Increased mortality with peptic ulcer bleeding in patients with both compensated and decompensated cirrhosis

BACKGROUND Cirrhosis is associated with worse outcomes in peptic ulcer bleeding (PUB). There are no population-based studies from the United States on the impact of cirrhosis on PUB outcomes. OBJECTIVE To investigate the impact of cirrhosis on outcomes of patients with PUB. DESIGN Cross-sectional study. SETTING Nationwide Inpatient Sample 2009. PATIENTS International Classification of Diseases, the 9th revision, codes were used to identify patients with PUB and cirrhosis. The control group was patients with PUB without cirrhosis. MAIN OUTCOME MEASUREMENTS In-hospital mortality, length of stay, and hospitalization costs. RESULTS A total of 96,887 discharges with PUB as a diagnosis were identified-3574 with PUB and cirrhosis and 93,313 with PUB alone without cirrhosis. Mortality of PUB with concomitant cirrhosis was higher than in the control group without cirrhosis (5.5% vs 2%; P = .01); decompensated cirrhosis had higher mortality than did compensated cirrhosis (6.6% vs 3.9%; P = .01). In multivariate analysis, the presence of cirrhosis independently increased mortality (adjusted odds ratio (aOR) 3.3; 95% confidence interval [CI], 2.2-4.9). Stratified analysis showed that decompensated cirrhosis (aOR 4.4; 95% CI, 2.6-7.3) had higher mortality than compensated cirrhosis (aOR 1.9; 95% CI, 1.04-3.6). There was no difference in the proportion of patients who underwent endoscopy within 24 hours (51.9% vs 51.1%; P = .68) between those with cirrhosis and controls. Patients with cirrhosis received less surgical intervention (aOR 0.8; 95% CI, 0.6-0.9) compared with controls. Hospitalization costs also were increased in patients with decompensated cirrhosis. LIMITATIONS Administrative data set. CONCLUSION Both decompensated and compensated cirrhosis are associated with increased mortality in patients with PUB.

In-class didactic versus self-directed teaching of the probe-based confocal laser endomicroscopy (pCLE) criteria for Barrett's esophagus.

BACKGROUND AND AIMS Optimal teaching methods for disease recognition using probe-based confocal laser endomicroscopy (pCLE) have not been developed. Our aim was to compare in-class didactic teaching vs. self-directed teaching of Barretts neoplasia diagnosis using pCLE. METHODS This randomized controlled trial was conducted at a tertiary academic center. Study participants with no prior pCLE experience were randomized to in-class didactic (group 1) or self-directed teaching groups (group 2). For group 1, an expert conducted a classroom teaching session using standardized educational material. Participants in group 2 were provided with the same material on an audio PowerPoint. After initial training, all participants graded an initial set of 20 pCLE videos and reviewed correct responses with the expert (group 1) or on audio PowerPoint (group 2). Finally, all participants completed interpretations of a further 40 videos. RESULTS Eighteen trainees (8 medical students, 10 gastroenterology trainees) participated in the study. Overall diagnostic accuracy for neoplasia prediction by pCLE was 77 % (95 % confidence interval [CI] 74.0 % - 79.2 %); of predictions made with high confidence (53 %), the accuracy was 85 % (95 %CI 81.8 % - 87.8 %). The overall accuracy and interobserver agreement was significantly higher in group 1 than in group 2 for all predictions (80.4 % vs. 73 %; P = 0.005) and for high confidence predictions (90 % vs. 80 %; P < 0.001). Following feedback (after the initial 20 videos), the overall accuracy improved from 73 % to 79 % (P = 0.04), mainly driven by a significant improvement in group 1 (74 % to 84 %; P < 0.01). Accuracy of prediction significantly improved with time in endoscopy training (72 % students, 77 % FY1, 82 % FY2, and 85 % FY3; P = 0.003). CONCLUSION For novice trainees, in-class didactic teaching enables significantly better recognition of the pCLE features of Barretts esophagus than self-directed teaching. The in-class didactic group had a shorter learning curve and were able to achieve 90 % accuracy for their high confidence predictions.

Patterns of antiplatelet agent use in the US

Background: The American Society of Gastrointestinal Endoscopy (ASGE) published updated guidelines in 2009 to help endoscopists manage the treatment of their patients who have been prescribed antiplatelet therapy (APT). Study aim: To assess the use of APT among endoscopists, and to identify factors guiding their use of APT while treating their patients. Method: A survey questionnaire was distributed to endoscopists at two national meetings to assess their usage of APT while treating patients during the peri-endoscopic period. Results: The survey was provided to 400 attendees of whom 239 (60 %) responded. Only 30 % of respondents followed the ASGE guidelines for treating their patients and 26 % percent of respondents withheld all APT before engaging in any patient procedure. Endoscopists’ decisions appeared to be influenced by their own particular experiences rather than any specific APT usage guidelines (46 % vs 22 %; P < 0.05). As expected, more endoscopists (P < 0.05) continued APT for patients who underwent low risk procedures (90 %) than for patients who underwent high risk procedures (47 %). Approximately 50 % of the respondents did not perform high risk procedures for patients prescribed aspirin therapy. Conclusions: About one-fourth of endoscopists surveyed discontinued APT treatment of patients who underwent any endoscopic procedure, and one-half of them discontinued use of non-steroidal anti-inflammatory drug treatment of patients who underwent a high risk endoscopic procedure. Inappropriate withdrawal of APT medications may expose patients to unnecessary risks, and efforts to improve endoscopists’ application of ASGE guidelines for the use of APT to treat patients during the peri-endoscopic period are warranted.