- Email: [email protected]
Abdominal Compression Administered Early by the Colonoscopist Shortened Insertion Time of Water Exchange Colonoscopy
AGA Abstracts
polypectomy bleed (n=7) and 13.6% in hep-bridge procedures (n=8; p<0.0747). Cardiovascular events occurred in 1.9% of procedures (n=4); 2.1% in the no-bridge (n=3) and 1.4% in the hep-bridge procedures (n=1; p<0.745). Thirty-day ER visits were seen in 14.2% (n= 18) of the no-bridge procedures and 42.3% (n=25) hep-bridge procedures (p<0.0001); this included urinary, musculoskeletal and orthostatic chief complaints. Neither CHADS2 (p<0.86) nor HASBLED (p<0.92) predicted post-polypectomy bleeding. CONCLUSION: In our cohort of anticoagulated patients undergoing colonoscopy, the use of a heparin bridge was not associated with increased gastrointestinal bleeding compared to cessation of anticoagulation, but was associated with a significant increase in ER visits within 30 days post-procedure. CHADS2 and HASBLED did not predict post-polypectomy bleeding. Table 1. Baseline Characteristics of post-polypectomy bleeding in heparin bridge therapy compared to interruption of anticoagulation.
Sa1022 CHRONIC PROTON PUMP INHIBITOR USE IN AMBULATORY CLINIC: IS YOUR DOCTOR ASKING THE RIGHT QUESTIONS? Osama Siddique, Anais Ovalle, Juliet Yirerong, Mohammad Arsalan Siddiqui, Salaheldin Elhamamsy Background Proton pump inhibitors (PPI) are one of the most common medications prescribed in the United States with around 15 million prescriptions in 2013 alone. Over the past decade there has been an increase in inappropriate prescribing of these medications. The overuse of these medications have led to increased healthcare expenditure alongside greater incidence of adverse effects. Our investigation evaluated how many patients in a resident run clinic were either started or continued on a PPI with or without a clear indication and whether discontinuation of the medication was addressed. Methods This was a retrospective chart review from a resident ambulatory care practice in a community hospital from July 1, 2015 to June 30, 2016. We analyzed the prescription trends of PPIs amongst Primary Care Providers (PCPs) from departments of Internal Medicine (IM) and Family Medicine (FM). All the patients with a PPI prescription were included. Patients with Barrett's esophagus, chronic NSAID (Ibuprofen/naproxen) use with bleeding risk, severe esophagitis per endoscopy report, history of gastrointestinal bleeding gastric ulcer, Zollinger-ellison syndrome and patients on medications such as Ranitidine, Famotidine, Cimetidine, Nizatidine, Ranitidine, Hydrochlorothiazide, Sodium Bicarbonate, Calcium carbonate antacids, Milk of Magnesia, Magnesium hydroxide, Aluminum hydroxide, Simethicone and Alginic acid were excluded. Binary logistic regression analysis was performed to examine associations between a deprescribing discussion and PCP gender. SPSS version 20 was used for analysis of the data. Results Out of a total of 767 patients on a PPI, 445 met the inclusion/exclusion criteria. Out of these 445 patients, 198 (44.5%) were males and 247 (55.5%) were females. The mean age of the patients was 56.6±16.1 years and 79.8% were whites while 20.2% were non-whites. 39% percent of PPI prescribing PCPs were males while 61% were females. PCPs belonging to IM were 21.1% and FM were 78.9%. Patients on chronic PPI prescription were 394 (88.5%), while the remaining were on PPIs for 194±134 days. Only 10.1% of the total number of patients had an endoscopy done, while 46.1% patients were on PPIs despite no gastrointestinal complaints recorded in their medical history. We discovered that only 10.1% PCPs discussed de-prescription, with female PCPs 2.5 times more likely to have this discussion compared to males. (p=0.004). Conclusion: With increasing healthcare costs and the adverse effects linked to PPIs, PCPs should be more conservative regarding PPI use. PCPs should remain vigilant when a PPI is prescribed and address the issue of deprescribing more frequently.
Sa1024 ABDOMINAL COMPRESSION ADMINISTERED EARLY BY THE COLONOSCOPIST SHORTENED INSERTION TIME OF WATER EXCHANGE COLONOSCOPY Yu-Hsi Hsieh, Chih Wei Tseng, Felix W. Leung Introduction: Of all the available colonoscopic maneuvers, withdrawal and straightening of the instrument is the single most important technique in instrument passage (Wade J. GastroHep.com 2001). The long insertion time of water exchange colonoscopy is a disincentive for its uptake. Traditionally an assistant is not asked to administer abdominal compression until the endoscopist has struggled for some time and failed to reduce the loops by withdrawal. During water exchange colonoscopy, the abdomen of the patient is quite soft so the abdominal compression can be administered easily. The loop formation during water exchange is less severe as compared with air insufflation and can be reduced quite readily. The colonoscopist can administer the abdominal compression whenever the scope is not advancing smoothly, probably in the early stage of loop formation. We test the hypothesis that colonoscopist administered abdominal compression to remove loops in their early stage of formation hastens cecal intubation. Method: Abdominal compression was administered during water exchange colonoscopy whenever the scope is not advancing smoothly. The colonoscopist used his right hand to compress the abdomen, while his left elbow supported the back of the patient. Hand pressure was applied to flatten the abdomen of the patient and then let go immediately. The compression was applied first at the left lower abdomen, then at the upper abdomen if the scope was in the transverse colon. The maneuver took only seconds to complete. The patients who received abdominal compressions applied by the colonoscopist were compared with an equal number of historical control subjects during the period immediately before start of the abdominal maneuvers. Results (Table 1): Compared with the historical controls, the need for assistant administered abdominal compression, the insertion time and the volume of water exchanged were significantly reduced. Conclusion: The reduced water volume likely reflects increased ease of insertion after the application of the abdominal compression to remove loops in the early stage of formation. The shortened insertion time is a welcomed improvement to water exchange colonoscopy. A randomized controlled trial to compare water exchange colonoscopy with and without colonoscopist administered abdominal compression in the early stage of loop formation deserves to be performed.
Sa1023 DO THE RISKS OUTWEIGH THE BENEFITS WHEN A HEPARIN BRIDGE IS USED FOR ANTICOAGULATED PATIENTS UNDERGOING COLONOSCOPY? Dionne Rebello, Mena Bakhit, Thomas R. McCarty, Peter Sidhom, Jason T. Machan, Margaret Quillin, Steven F. Moss BACKGROUND AND AIM: Anticoagulation management for patients undergoing colonoscopy includes the interruption of anticoagulation with or without use of a heparin bridge. The primary aim of this study was to assess the adverse events associated with heparin bridge (hep-bridge) therapy compared to temporary cessation of anticoagulation without bridge (no-bridge). METHODS: This single center, retrospective cohort study used electronic medical records to identify all anticoagulated patients who underwent colonoscopy between January 2015 and November 2016. In the no-bridge cohort, NOACs (novel oral anticoagulation) were held two days and warfarin was held 5 days pre-procedure and reinitiated immediately following colonoscopy. In the hep-bridge cohort, warfarin or NOACs were held and subcutaneous LMWH (enoxaparin 1 mg/kg BID) was started 5 days prior to procedure. LMWH was held on the day of colonoscopy and warfarin or NOACs was restarted post procedure. LMWH was reinitiated one-day post procedure for 5 days. The primary outcome measure was post-polypectomy bleeding, defined as a chief complaint of rectal bleeding upon post-procedure emergency room (ER) or outpatient office visit within 30 days of the procedure. Secondary outcomes included cardiovascular events, all cause complications, ER visits within 30 days, and predictive value of the HASBLED and CHADS2 scores for 30 day ER visits. RESULTS: A total of 205 patients were included and 186 of those patients underwent polypectomy (87.7%). The mean age was 68.4 years and 96.6% were male. There were 139 procedures performed with no-bridge and 66 procedures with hep-bridge. Interventions and outcomes are summarized in Table I. Post-polypectomy bleeding was seen in a total of 7.1% (n=15) of procedures. In the no-bridge cohort a total of 5.5% had a post
AGA Abstracts
S-224
Sa1026 REAL-TIME COMMUNICATION OF A CLINICAL PATHWAY FOR UPPER GASTROINTESTINAL BLEEDING THROUGH SECURE TEXT MESSAGING William Bassett, Shazia M. Siddique, Benjamin L. Ranard, Yevgeniy Gitelman, Carolyn Newberry, Nikhil Mull, Subha Airan-Javia, Mary Coniglio, David C. Metz, Nuzhat A. Ahmad, Shivan Mehta Background Clinical decision support interventions have demonstrated mixed success. We developed a clinical pathway for the management of patients with upper gastrointestinal bleeding (UGIB) based on a literature review and expert consensus of a multi-disciplinary team (Image 1). We sought to determine the effectiveness of secure text messaging of the pathway in real-time to covering providers caring for patients with an UGIB by surveying recipients of the pathway after clinical decision making and measuring potential changes in outcomes. Methods Starting May 2016, inpatients at the Hospital of the University of Pennsylvania were identified in real-time as having a suspected UGIB if an order was placed for a pantoprazole infusion (PPI). An hour after the order for PPI was placed, the patient's covering provider was automatically sent the UGIB clinical pathway using a secure text messaging service. In the months of May and August 2016, feedback about the pathway was solicited 48 hours after the pathway was sent. Length of stay was also measured preand post-intervention as an exploratory outcome. This project was reviewed and determined to qualify as quality improvement by the IRB. Results 116 patients were ordered PPI infusions in May and August. 88 (75.8%) of these patients' providers were sent the pathway. 43 (48.9%) of the receiving providers gave feedback on the utility of the pathway and alert after solicitation, including 21 of whom (48.8%) viewed it, 12 of whom (27.9%) stated it increased their confidence in patient care, and 1 of whom (2.3%) felt it changed their management. The most common reason given for not affecting management of the patient was that gastroenterology (GI) consultation drove management decisions by the admitting team. Clinical decisions, such as transfusion goal and inpatient PPI dose, were regularly included in consulting GI recommendations and were largely concordant with pathway recommendations. Consulting recommendations and discharge instructions rarely included longer-term pathway recommendations such as duration of PPI therapy, follow-up interval, and future testing and procedures. Median length of stay was 5.5 days in the 16 months pre-implementation and 5.1 days in the 5 months post-implementation, but not statistically significant. Discussion Text messaging can be an effective way to deliver care pathways to providers in the hospital. This pilot demonstrated the feasibility of identifying patients in real-time and automatically sending secure text messages to the covering inpatient provider. This approach may not change patient related outcomes for UGIB without targeting both primary and consulting teams. Another potential approach is to embed the care pathway into a standard framework for work management and documentation by the GI consult team.
ADR, adenoma detection rate; SD, standard deviation; yr, years; P value indicating that Mann-Whitney U test was used for continuous variables and the Fisher exact or Chi square test for categorical variables.
Sa1025 CURRENT UTILIZATION AND DIAGNOSTIC YIELD OF RANDOM COLONIC BIOPSIES IN EVALUATION OF CHRONIC DIARRHEA Xin Zhang, Laura Pestana, Sunanda V. Kane Background and Aims Chronic diarrhea affects up to 5 percent of the population. Current guidelines recommend performing random biopsies for evaluation of microscopic colitis if macroscopic colonoscopy evaluation is normal. The yield of random biopsies for microscopic colitis has been shown to be low (10-14%). As part of a larger quality improvement program, we aimed to study current practice at our tertiary center as to rationale for why random biopsies were not performed when the indication for colonoscopy was "diarrhea", and determine the yield of those biopsies. Methods Retrospective chart review was performed on all outpatient colonoscopies done for the indication "diarrhea" from October 2012 to May 2014. Pertinent patient information including age and sex, clinical variables (duration of symptoms, number of bowel movements, presence of nocturnal bowel movements, anemia and weight loss), and histology were collected. Results Six hundred twenty-one colonoscopies were done for the indication "diarrhea." There were 425 female patients and 196 male patients. Average age was 47 years (range 17 to 93 years). Chronic diarrhea was documented in 513 cases (82%); acute diarrhea was documented in 59 cases (10%). 94 of patients had documented anemia; 172 patients had documented weight loss. Random biopsies were performed in 613 procedures (98.7%) and not collected in 8 colonoscopies (1.3%). Reasons for not pursuing random biopsies included active diverticulitis (1), wrong indication of procedure (2), procedure aborted due to patient instability (2), acute diarrhea that selfresolved by time of colonoscopy (1), and colonoscopy done for fecal microbiota transplant (2). One hundred forty patients yielded abnormal findings (23%), while 474 showed normal histology (77%). Microscopic colitis was found in 73 cases (12%), collagenous in 29 (5%) and lymphocytic colitis in 44 (7%). Other pathological findings included non-specific acute colitis (11), amyloid (2), CMV colitis (1), graft versus host disease (1), and mycobacterium avium-intracellulare infection (1). Conclusion Our study demonstrates high instructional compliance with current guidelines to obtain random biopsies in a history of chronic diarrhea. Random biopsies were not obtained only in instances where there was not a valid clinical indication. In addition, the yield of random biopsies at 12% was congruent with previous studies at other institutions. Continued efforts to educate our non-GI colleagues on proper referral for invasive procedures will hopefully lead to higher yields in the future.
Upper Gastrointestinal Bleeding Pathway
Sa1027 SAFETY OF GASTROINTESTINAL ENDOSCOPY PERFORMED WITH MONITORED ANESTHESIA CARE (MAC) SEDATION COMPARED WITH CONSCIOUS SEDATION IN PATIENTS WITH OBSTRUCTIVE SLEEP APNEA Jonathan E. Hilal, Miguel Lalama, Ambuj Kumar, Donald Amodeo, Prasad Kulkarni, Jeffrey Gill, Jonathan Keshishian, Susan Goldsmith, Barbara Bachman, Robert Hadesman, Judith Parow, Irfan Hashimie, Gitanjali Vidyarthi Introduction: Patients with obstructive sleep apnea (OSA) undergoing gastrointestinal endoscopy are considered by practitioners to be at a higher risk for cardiopulmonary complications. We have demonstrated in prior studies the safety of conscious sedation in patients with OSA. The aim of the current study was to evaluate and compare the safety of monitored anesthesia care (MAC) sedation versus conscious sedation in patients with OSA whom are
S-225
AGA Abstracts
AGA Abstracts
Table 1. Characteristics of patients receiving abdominal compression by colonoscopist and historical controls
polypectomy bleed (n=7) and 13.6% in hep-bridge procedures (n=8; p<0.0747). Cardiovascular events occurred in 1.9% of procedures (n=4); 2.1% in the no-bridge (n=3) and 1.4% in the hep-bridge procedures (n=1; p<0.745). Thirty-day ER visits were seen in 14.2% (n= 18) of the no-bridge procedures and 42.3% (n=25) hep-bridge procedures (p<0.0001); this included urinary, musculoskeletal and orthostatic chief complaints. Neither CHADS2 (p<0.86) nor HASBLED (p<0.92) predicted post-polypectomy bleeding. CONCLUSION: In our cohort of anticoagulated patients undergoing colonoscopy, the use of a heparin bridge was not associated with increased gastrointestinal bleeding compared to cessation of anticoagulation, but was associated with a significant increase in ER visits within 30 days post-procedure. CHADS2 and HASBLED did not predict post-polypectomy bleeding. Table 1. Baseline Characteristics of post-polypectomy bleeding in heparin bridge therapy compared to interruption of anticoagulation.
Sa1022 CHRONIC PROTON PUMP INHIBITOR USE IN AMBULATORY CLINIC: IS YOUR DOCTOR ASKING THE RIGHT QUESTIONS? Osama Siddique, Anais Ovalle, Juliet Yirerong, Mohammad Arsalan Siddiqui, Salaheldin Elhamamsy Background Proton pump inhibitors (PPI) are one of the most common medications prescribed in the United States with around 15 million prescriptions in 2013 alone. Over the past decade there has been an increase in inappropriate prescribing of these medications. The overuse of these medications have led to increased healthcare expenditure alongside greater incidence of adverse effects. Our investigation evaluated how many patients in a resident run clinic were either started or continued on a PPI with or without a clear indication and whether discontinuation of the medication was addressed. Methods This was a retrospective chart review from a resident ambulatory care practice in a community hospital from July 1, 2015 to June 30, 2016. We analyzed the prescription trends of PPIs amongst Primary Care Providers (PCPs) from departments of Internal Medicine (IM) and Family Medicine (FM). All the patients with a PPI prescription were included. Patients with Barrett's esophagus, chronic NSAID (Ibuprofen/naproxen) use with bleeding risk, severe esophagitis per endoscopy report, history of gastrointestinal bleeding gastric ulcer, Zollinger-ellison syndrome and patients on medications such as Ranitidine, Famotidine, Cimetidine, Nizatidine, Ranitidine, Hydrochlorothiazide, Sodium Bicarbonate, Calcium carbonate antacids, Milk of Magnesia, Magnesium hydroxide, Aluminum hydroxide, Simethicone and Alginic acid were excluded. Binary logistic regression analysis was performed to examine associations between a deprescribing discussion and PCP gender. SPSS version 20 was used for analysis of the data. Results Out of a total of 767 patients on a PPI, 445 met the inclusion/exclusion criteria. Out of these 445 patients, 198 (44.5%) were males and 247 (55.5%) were females. The mean age of the patients was 56.6±16.1 years and 79.8% were whites while 20.2% were non-whites. 39% percent of PPI prescribing PCPs were males while 61% were females. PCPs belonging to IM were 21.1% and FM were 78.9%. Patients on chronic PPI prescription were 394 (88.5%), while the remaining were on PPIs for 194±134 days. Only 10.1% of the total number of patients had an endoscopy done, while 46.1% patients were on PPIs despite no gastrointestinal complaints recorded in their medical history. We discovered that only 10.1% PCPs discussed de-prescription, with female PCPs 2.5 times more likely to have this discussion compared to males. (p=0.004). Conclusion: With increasing healthcare costs and the adverse effects linked to PPIs, PCPs should be more conservative regarding PPI use. PCPs should remain vigilant when a PPI is prescribed and address the issue of deprescribing more frequently.
Sa1024 ABDOMINAL COMPRESSION ADMINISTERED EARLY BY THE COLONOSCOPIST SHORTENED INSERTION TIME OF WATER EXCHANGE COLONOSCOPY Yu-Hsi Hsieh, Chih Wei Tseng, Felix W. Leung Introduction: Of all the available colonoscopic maneuvers, withdrawal and straightening of the instrument is the single most important technique in instrument passage (Wade J. GastroHep.com 2001). The long insertion time of water exchange colonoscopy is a disincentive for its uptake. Traditionally an assistant is not asked to administer abdominal compression until the endoscopist has struggled for some time and failed to reduce the loops by withdrawal. During water exchange colonoscopy, the abdomen of the patient is quite soft so the abdominal compression can be administered easily. The loop formation during water exchange is less severe as compared with air insufflation and can be reduced quite readily. The colonoscopist can administer the abdominal compression whenever the scope is not advancing smoothly, probably in the early stage of loop formation. We test the hypothesis that colonoscopist administered abdominal compression to remove loops in their early stage of formation hastens cecal intubation. Method: Abdominal compression was administered during water exchange colonoscopy whenever the scope is not advancing smoothly. The colonoscopist used his right hand to compress the abdomen, while his left elbow supported the back of the patient. Hand pressure was applied to flatten the abdomen of the patient and then let go immediately. The compression was applied first at the left lower abdomen, then at the upper abdomen if the scope was in the transverse colon. The maneuver took only seconds to complete. The patients who received abdominal compressions applied by the colonoscopist were compared with an equal number of historical control subjects during the period immediately before start of the abdominal maneuvers. Results (Table 1): Compared with the historical controls, the need for assistant administered abdominal compression, the insertion time and the volume of water exchanged were significantly reduced. Conclusion: The reduced water volume likely reflects increased ease of insertion after the application of the abdominal compression to remove loops in the early stage of formation. The shortened insertion time is a welcomed improvement to water exchange colonoscopy. A randomized controlled trial to compare water exchange colonoscopy with and without colonoscopist administered abdominal compression in the early stage of loop formation deserves to be performed.
Sa1023 DO THE RISKS OUTWEIGH THE BENEFITS WHEN A HEPARIN BRIDGE IS USED FOR ANTICOAGULATED PATIENTS UNDERGOING COLONOSCOPY? Dionne Rebello, Mena Bakhit, Thomas R. McCarty, Peter Sidhom, Jason T. Machan, Margaret Quillin, Steven F. Moss BACKGROUND AND AIM: Anticoagulation management for patients undergoing colonoscopy includes the interruption of anticoagulation with or without use of a heparin bridge. The primary aim of this study was to assess the adverse events associated with heparin bridge (hep-bridge) therapy compared to temporary cessation of anticoagulation without bridge (no-bridge). METHODS: This single center, retrospective cohort study used electronic medical records to identify all anticoagulated patients who underwent colonoscopy between January 2015 and November 2016. In the no-bridge cohort, NOACs (novel oral anticoagulation) were held two days and warfarin was held 5 days pre-procedure and reinitiated immediately following colonoscopy. In the hep-bridge cohort, warfarin or NOACs were held and subcutaneous LMWH (enoxaparin 1 mg/kg BID) was started 5 days prior to procedure. LMWH was held on the day of colonoscopy and warfarin or NOACs was restarted post procedure. LMWH was reinitiated one-day post procedure for 5 days. The primary outcome measure was post-polypectomy bleeding, defined as a chief complaint of rectal bleeding upon post-procedure emergency room (ER) or outpatient office visit within 30 days of the procedure. Secondary outcomes included cardiovascular events, all cause complications, ER visits within 30 days, and predictive value of the HASBLED and CHADS2 scores for 30 day ER visits. RESULTS: A total of 205 patients were included and 186 of those patients underwent polypectomy (87.7%). The mean age was 68.4 years and 96.6% were male. There were 139 procedures performed with no-bridge and 66 procedures with hep-bridge. Interventions and outcomes are summarized in Table I. Post-polypectomy bleeding was seen in a total of 7.1% (n=15) of procedures. In the no-bridge cohort a total of 5.5% had a post
AGA Abstracts
S-224
Sa1026 REAL-TIME COMMUNICATION OF A CLINICAL PATHWAY FOR UPPER GASTROINTESTINAL BLEEDING THROUGH SECURE TEXT MESSAGING William Bassett, Shazia M. Siddique, Benjamin L. Ranard, Yevgeniy Gitelman, Carolyn Newberry, Nikhil Mull, Subha Airan-Javia, Mary Coniglio, David C. Metz, Nuzhat A. Ahmad, Shivan Mehta Background Clinical decision support interventions have demonstrated mixed success. We developed a clinical pathway for the management of patients with upper gastrointestinal bleeding (UGIB) based on a literature review and expert consensus of a multi-disciplinary team (Image 1). We sought to determine the effectiveness of secure text messaging of the pathway in real-time to covering providers caring for patients with an UGIB by surveying recipients of the pathway after clinical decision making and measuring potential changes in outcomes. Methods Starting May 2016, inpatients at the Hospital of the University of Pennsylvania were identified in real-time as having a suspected UGIB if an order was placed for a pantoprazole infusion (PPI). An hour after the order for PPI was placed, the patient's covering provider was automatically sent the UGIB clinical pathway using a secure text messaging service. In the months of May and August 2016, feedback about the pathway was solicited 48 hours after the pathway was sent. Length of stay was also measured preand post-intervention as an exploratory outcome. This project was reviewed and determined to qualify as quality improvement by the IRB. Results 116 patients were ordered PPI infusions in May and August. 88 (75.8%) of these patients' providers were sent the pathway. 43 (48.9%) of the receiving providers gave feedback on the utility of the pathway and alert after solicitation, including 21 of whom (48.8%) viewed it, 12 of whom (27.9%) stated it increased their confidence in patient care, and 1 of whom (2.3%) felt it changed their management. The most common reason given for not affecting management of the patient was that gastroenterology (GI) consultation drove management decisions by the admitting team. Clinical decisions, such as transfusion goal and inpatient PPI dose, were regularly included in consulting GI recommendations and were largely concordant with pathway recommendations. Consulting recommendations and discharge instructions rarely included longer-term pathway recommendations such as duration of PPI therapy, follow-up interval, and future testing and procedures. Median length of stay was 5.5 days in the 16 months pre-implementation and 5.1 days in the 5 months post-implementation, but not statistically significant. Discussion Text messaging can be an effective way to deliver care pathways to providers in the hospital. This pilot demonstrated the feasibility of identifying patients in real-time and automatically sending secure text messages to the covering inpatient provider. This approach may not change patient related outcomes for UGIB without targeting both primary and consulting teams. Another potential approach is to embed the care pathway into a standard framework for work management and documentation by the GI consult team.
ADR, adenoma detection rate; SD, standard deviation; yr, years; P value indicating that Mann-Whitney U test was used for continuous variables and the Fisher exact or Chi square test for categorical variables.
Sa1025 CURRENT UTILIZATION AND DIAGNOSTIC YIELD OF RANDOM COLONIC BIOPSIES IN EVALUATION OF CHRONIC DIARRHEA Xin Zhang, Laura Pestana, Sunanda V. Kane Background and Aims Chronic diarrhea affects up to 5 percent of the population. Current guidelines recommend performing random biopsies for evaluation of microscopic colitis if macroscopic colonoscopy evaluation is normal. The yield of random biopsies for microscopic colitis has been shown to be low (10-14%). As part of a larger quality improvement program, we aimed to study current practice at our tertiary center as to rationale for why random biopsies were not performed when the indication for colonoscopy was "diarrhea", and determine the yield of those biopsies. Methods Retrospective chart review was performed on all outpatient colonoscopies done for the indication "diarrhea" from October 2012 to May 2014. Pertinent patient information including age and sex, clinical variables (duration of symptoms, number of bowel movements, presence of nocturnal bowel movements, anemia and weight loss), and histology were collected. Results Six hundred twenty-one colonoscopies were done for the indication "diarrhea." There were 425 female patients and 196 male patients. Average age was 47 years (range 17 to 93 years). Chronic diarrhea was documented in 513 cases (82%); acute diarrhea was documented in 59 cases (10%). 94 of patients had documented anemia; 172 patients had documented weight loss. Random biopsies were performed in 613 procedures (98.7%) and not collected in 8 colonoscopies (1.3%). Reasons for not pursuing random biopsies included active diverticulitis (1), wrong indication of procedure (2), procedure aborted due to patient instability (2), acute diarrhea that selfresolved by time of colonoscopy (1), and colonoscopy done for fecal microbiota transplant (2). One hundred forty patients yielded abnormal findings (23%), while 474 showed normal histology (77%). Microscopic colitis was found in 73 cases (12%), collagenous in 29 (5%) and lymphocytic colitis in 44 (7%). Other pathological findings included non-specific acute colitis (11), amyloid (2), CMV colitis (1), graft versus host disease (1), and mycobacterium avium-intracellulare infection (1). Conclusion Our study demonstrates high instructional compliance with current guidelines to obtain random biopsies in a history of chronic diarrhea. Random biopsies were not obtained only in instances where there was not a valid clinical indication. In addition, the yield of random biopsies at 12% was congruent with previous studies at other institutions. Continued efforts to educate our non-GI colleagues on proper referral for invasive procedures will hopefully lead to higher yields in the future.
Upper Gastrointestinal Bleeding Pathway
Sa1027 SAFETY OF GASTROINTESTINAL ENDOSCOPY PERFORMED WITH MONITORED ANESTHESIA CARE (MAC) SEDATION COMPARED WITH CONSCIOUS SEDATION IN PATIENTS WITH OBSTRUCTIVE SLEEP APNEA Jonathan E. Hilal, Miguel Lalama, Ambuj Kumar, Donald Amodeo, Prasad Kulkarni, Jeffrey Gill, Jonathan Keshishian, Susan Goldsmith, Barbara Bachman, Robert Hadesman, Judith Parow, Irfan Hashimie, Gitanjali Vidyarthi Introduction: Patients with obstructive sleep apnea (OSA) undergoing gastrointestinal endoscopy are considered by practitioners to be at a higher risk for cardiopulmonary complications. We have demonstrated in prior studies the safety of conscious sedation in patients with OSA. The aim of the current study was to evaluate and compare the safety of monitored anesthesia care (MAC) sedation versus conscious sedation in patients with OSA whom are
S-225
AGA Abstracts
AGA Abstracts
Table 1. Characteristics of patients receiving abdominal compression by colonoscopist and historical controls