Stephanie Judd

The Impact of Bowel Cleansing on Follow-Up Recommendations in Average-Risk Patients With a Normal Colonoscopy

OBJECTIVES:Repeat colonoscopy in 10 years after a normal screening colonoscopy is recommended in an average-risk patient, and it has been proposed by American Gastroenterological Association (AGA), American College of Gastroenterology (ACG), and American Society for Gastrointestinal Endoscopy (ASGE) as a quality measure. However, there are little quantitative data about adherence to this recommendation or factors that may improve adherence. Our study quantifies adherence to this recommendation and the impact of suboptimal bowel preparation on adherence.METHODS:In this retrospective database study, endoscopy reports of average-risk individuals ≥50 years old with a normal screening colonoscopy were reviewed. Quality of colon cleansing was recorded using the Aronchick scale as excellent, good, fair, or poor. Main outcome measurements were quality of bowel preparation and recommendation for timing of repeat colonoscopy. Recommendations were considered consistent with guidelines if 10-year follow-up was documented after excellent, good, or fair prep or if ≤1-year follow-up was recommended after poor prep.RESULTS:Among 1,387 eligible patients, recommendations for follow-up colonoscopy inconsistent with guidelines were seen in 332 (23.9%) subjects. By bowel preparation quality, 15.3% of excellent/good, 75% of fair, and 31.6% of poor bowel preparations were assigned recommendations inconsistent with guidelines (P<0.001). Patients with fair (odds ratio=18.0; 95% confidence interval 12.0–28.0) were more likely to have recommendations inconsistent with guidelines compared with patients with excellent/good preps.CONCLUSIONS:Recommendations inconsistent with guidelines for 10-year intervals after a normal colonoscopy occurred in >20% of patients. Minimizing “fair” bowel preparations may be a helpful intervention to improve adherence to these recommendations.

Role of cancer stem cells in racial disparity in colorectal cancer.

Although African‐Americans (AAs) have a higher incidence of colorectal cancer (CRC) than White people, the underlying biochemical mechanisms for this increase are poorly understood. The current investigation was undertaken to examine whether differences in self‐renewing cancer stem/stem‐like cells (CSCs) in the colonic mucosa, whose stemness is regulated by certain microRNAs (miRs), could partly be responsible for the racial disparity in CRC. The study contains 53 AAs and 47 White people. We found the number of adenomas and the proportion of CD44+CD166− CSC phenotype in the colon to be significantly higher in AAs than White people. MicroRNAs profile in CSC‐enriched colonic mucosal cells, expressed as ratio of high‐risk (≥3 adenomas) to low‐risk (no adenoma) CRC patients revealed an 8‐fold increase in miR‐1207‐5p in AAs, compared to a 1.2‐fold increase of the same in White people. This increase in AA was associated with a marked rise in lncRNA PVT1 (plasmacytoma variant translocation 1), a host gene of miR‐1207‐5p. Forced expression of miR‐1207‐5p in normal human colonic epithelial cells HCoEpiC and CCD841 produced an increase in stemness, as evidenced by morphologically elongated epithelial mesenchymal transition( EMT) phenotype and significant increases in CSC markers (CD44, CD166, and CD133) as well as TGF‐β, CTNNB1, MMP2, Slug, Snail, and Vimentin, and reduction in Twist and N‐Cadherin. Our findings suggest that an increase in CSCs, specifically the CD44+CD166− phenotype in the colon could be a predisposing factor for the increased incidence of CRC among AAs. MicroRNA 1207‐5p appears to play a crucial role in regulating stemness in colonic epithelial cells in AAs.

Tu1047 Assessing Key Barriers to Treatment of Chronic Hepatitis C Virus (HCV) With Next Generation Agents in a Veteran Population

variability was noted in the responses, with some waiting as long as 5 years to repeat screening in the presence of a high-risk adenoma with IBP. Awareness of MSTF recommendations or adherence to these guidelines still remains weak among GI physicians and physician-extenders. Publicity of guidelines and further data to support their recommendations are warranted. REFERENCES 1.Lebwohl B, et al. Gastrointest Endosc 2011;73(6):1207-1214. 2.Neerincx M, et al. Endoscopy 2010;42(9):730-735. 3.Lieberman DA, et al. Gastroenterology 2012;143(3):844-57.

Approach to Presenting a Clinical Journal Club

It can be a daunting assignment thatmost traineeswill face at some point in their careers: Selecting, appraising, and presenting an article for a clinical journal club. Thoughts of where to begin looking for an article arise, which is often followed by apprecase-control studies, and meta-analyses can occasionally be chosen. Case reports and review articles are not appropriate for this purpose and should be avoided. Although past landmark articles can be considered because they often represent the foundation of current clinical practice, we recommend choosing an article that has been published recently, preferably within the last 3–6 months, and has received attention at major GI conferences and through the lay press. This way, a “cutting-edge” topic can be presented, which your audience should hopefully already be familiar with, leading to a more productive discussion. The American College of Physicians Journal Club can be an excellent resource, as it incorporates the McMaster Online Rating of hension about interpreting statistical tests and critically analyzing the article. Finally comes the task of presenting the article and leading a focused group discussion. Despite the unease that can accompany these tasks, honing the skills necessary for article appraisal and succinct presentation are important. They are essential not only for an effective journal club presentation in residency and fellowship, but also for development into an astute, evidence-based clinician. Clinical journal clubs also provide an excellent opportunity to discuss new innovations in gastroenterology that shape our clinical practice. Here we present an approach (Table 1) that walks the reader through the steps necessary for preparation and successful presentation of a clinical article at journal club.

Predictors of suboptimal bowel preparation in asymptomatic patients undergoing average-risk screening colonoscopy

AIM To identify risk factors for a suboptimal preparation among a population undergoing screening or surveillance colonoscopy. METHODS Retrospective review of the University of Michigan and Veterans Administration (VA) Hospital records from 2009 to identify patients age 50 and older who underwent screening or surveillance procedure and had resection of polyps less than 1 cm in size and no more than 2 polyps. Patients with inflammatory bowel disease or a family history of colorectal cancer were excluded. Suboptimal procedures were defined as procedure preparations categorized as fair, poor or inadequate by the endoscopist. Multivariable logistic regression was used to identify predictors of suboptimal preparation. RESULTS Of 4427 colonoscopies reviewed, 2401 met our inclusion criteria and were analyzed. Of our population, 16% had a suboptimal preparation. African Americans were 70% more likely to have a suboptimal preparation (95%CI: 1.2-2.4). Univariable analysis revealed that narcotic and tricyclic antidepressants (TCA) use, diabetes, prep type, site (VA vs non-VA), and presence of a gastroenterology (GI) fellow were associated with suboptimal prep quality. In a multivariable model controlling for gender, age, ethnicity, procedure site and presence of a GI fellow, diabetes [odds ratio (OR) = 2.3; 95%CI: 1.6-3.2], TCA use (OR = 2.5; 95%CI: 1.3-4.9), narcotic use (OR = 1.7; 95%CI: 1.2-2.5) and Miralax-Gatorade prep vs 4L polyethylene glycol 3350 (OR = 0.6; 95%CI: 0.4-0.9) were associated with a suboptimal prep quality. CONCLUSION Diabetes, narcotics use and TCA use were identified as predictors of poor preparation in screening colonoscopies while Miralax-Gatorade preps were associated with better bowel preparation.

Gut microbiome profiling and colorectal cancer in African Americans and Caucasian Americans

AIM To determine whether and to what extent the gut microbiome is involved in regulating racial disparity in colorectal cancer (CRC). METHODS All patients were recruited and experiments were performed in accordance with the relevant guidelines and regulations by the Institutional Review Boards (IRB), committees of the John D. Dingell VAMC and Wayne State University guidelines. African American (AA) and Caucasian American (CA) patients were scheduled for an outpatient screening for colonoscopy, and no active malignancy volunteer patients were doubly consented, initially by the gastroenterologist and later by the study coordinator, for participation in the study. The gut microbial communities in colonic effluents from AAs and CAs were examined using 16sRNA profiling, and bacterial identifications were validated by performing SYBR-based Real Time PCR. For metagenomic analysis to characterize the microbial communities, multiple software/tools were used, including Metastats and R statistical software. RESULTS It is generally accepted that the incidence and mortality of CRC is higher in AAs than in CAs. However, the reason for this disparity is not well understood. We hypothesize that the gut microbiome plays a role in regulating this disparity. Indeed, we found significant differences in species richness and diversity between AAs and CAs. Bacteroidetes was more abundant in AAs than in CAs. In particular, the pro-inflammatory bacteria Fusobacterium nucleatum and Enterobacter species were significantly higher in AAs, whereas probiotic Akkermansia muciniphila and Bifidobacterium were higher in CAs. The polyphyletic Clostridia class showed a divergent pattern, with Clostridium XI elevated in AAs, and Clostridium IV, known for its beneficial function, higher in CAs. Lastly, the AA group had decreased microbial diversity overall in comparison to the CA group. In summary, there were significant differences in pro-inflammatory bacteria and microbial diversity between AA and CA, which may help explain the CRC disparity between groups. CONCLUSION Our current investigation, for the first time, demonstrates microbial dysbiosis between AAs and CAs, which could contribute to the racial disparity of CRC.

Brunner's gland hamartoma: a rare cause of iron deficiency anaemia and report of an adapted colonic polyp resection technique.

A man aged 65 years presented with symptomatic anaemia without overt gastrointestinal bleeding. An oesophagogastroduodenoscopy (EGD) was performed and he was found to have a large ulcerated pedunculated Brunners gland hamartoma in the duodenal bulb. The polyp was resected using snare cautery in forward and retroflexed positions. Colonoscopy was also performed and a few diminutive polyps were resected. A year later, the patient returned for a surveillance EGD, and no residual polyp was noted. Haemoglobin and iron studies normalised within a few months after polypectomy, with resolution of symptoms.

The “pot-of-gold” sign: not always a lipoma

follow-up): 44 (48.4%) had K-ras wild-type tumors, and 47 (51.6%) had K-ras mutated cancers. Eighty-two patients (90.1%) underwent chemotherapy, and 45 of them (49.5%) received additional biologic therapy (11 cetuximab, 34 bevacizumab). After a mean follow-up time of 251 days, 21 (23.1%) SEMS-related adverse events were reported; K-ras mutation status and cetuximab-based treatments (odds ratio 1.2; 95% confidence interval, 0.2-5.9) were not associated with any of them. Several genetic pathways and mutations are increasingly recognized as prognostic factors in CRC patients. Therefore, future research should also aim at the identification of those risk factors related to CRC biology, for better stratifying patients with colorectal obstruction who will benefit the most from SEMSs.

A Rare Finding on Evaluation for Iron Deficiency Anemia

Gastroenterology 2014;146:e8–e9 Question: A 53year-old man with no significant past medical history was referred to Gastroenterology for evaluation of iron deficiency anemia. He denied melena, hematochezia, hematemesis, or any overt bleeding. He denied abdominal pain, dyspepsia, chest pain, or shortness of breath; complete review of systems was negative. General physical examination was within normal limits. Initial work-up included esophagogastroduodenoscopy, which was normal, and colonoscopy, which showed two adenomatous polyps. Video capsule endoscopy was subsequently completed, which showed possible extrinsic compression versus submucosal mass in the middle third of the small bowel. To further evaluate these video capsule endoscopy findings, computed tomography enterography was performed (Figure A–D).