- Email: [email protected]
M1066 Protocol Development for the Management of Button Battery-Induced Aortoesophageal Fistula in Children
M1063
inflammation precisely in UC patients. Methods: Retrospective analysis of 545 total colonoscopic examinations for UC patients was performed. Severity of mucosal inflammation was evaluated using the Mayo score of endoscopic index at each location (rectum, sigmoid colon, descending colon, and the oral side of splenic flexure) in each UC patient. The colonic site with maximum inflammation in each patent was determined. If there are two or more colonic locations with the same maximum severity, the location nearest to the anal was used for analysis. In addition, if a patient has no inflammation (Mayo 0) throughout the colon, the rectum was evaluated as the location with maximum severity. Results: Of 545 patients, 314 (58%) have maximum inflammation in the rectum, 93 (17%) in the sigmoid colon, 55 (10%) in the descending colon, and 83 (15%) in the oral side of the splenic flexure. Namely, sigmoidoscopy is insufficient for 25% of UC patients for evaluating inflammation precisely. Patients were divided into two groups: those with maximum severity in the rectum or sigmoid colon (group I), and those with maximum severity in the descending colon or the oral side of splenic flexure (group II). The first-attack patients are significantly more frequently observed in the group II than in the group I (group I 6% vs. group II 17%, p < 0.0001). In addition, patients with no or mild inflammation (Mayo score = 0 or 1) in the rectum or sigmoid colon are more common in the group II than in the group I (group I 52% vs. group II 71%, p < 0.0001). Lastly, we analyzed 134 patients with no inflammation in the rectum and sigmoid colon. Among these patients, inflammatory mucosa in the descending colon or the oral side of the splenic flexure was observed in 54 (40%). Even in the 125 patients with clinically remission, 45 (36%) have inflammatory mucosa in the descending colon or the oral side of the splenic flexure. Conclusions: Sigmoidoscopy is not sufficient for evaluating inflammation precisely in UC patients. In particular, total colonoscopy is quite necessary in patients with first attack and in patients who have discrepancy between endoscopic features in the rectum or sigmoid colon and patient symptoms.
AGA Abstracts
Diurnal and Day-of-Week Variation in Polyp Detection Rate Gregory W. Munson, Dawn L. Francis INTRODUCTION: Colonoscopy reduces colon cancer risk by removing polyps. Research has shown that increased polyp detection rate (PDR) correlates with longer withdrawal time (WT), fellow assistance, and earlier time of day. It is unclear whether PDR varies by day of week (DOW). Mayo Clinic Rochester (MCR) schedules endoscopists for three 3-hour shifts daily. The current study examines daily shift and DOW variance in PDR at MCR and whether such variance correlates with WT. METHODS: Colonoscopies in 2008 with cecal intubation were identified in our endoscopy database. Inclusion criteria: (1) average-risk screening exams, (2) colon preparations graded fair adequate or better, (3) no fellow participation, and (4) performance by staff endoscopists with more than 100 colonoscopies in 2008. During exams, endoscopy nurses entered time stamps in the database to mark the proximal extent and end of each procedure; and WT is the difference for colonoscopies in which no polypectomy was performed. PDR is the number of colonoscopies with at least one polyp divided by total colonoscopies. PDR and WT by individual endoscopists were analyzed with Pearson's correlation (ρ). For daily shift and DOW, PDR was analyzed with chi-square (χ2), and one-way analysis of variation (ANOVA) was used to compare WT. Colorectal surgeons at MCR do not work standard 3-hour shifts and were excluded from shift analysis. RESULTS: There were 14,839 complete colonoscopies in the main MCR endoscopy unit in 2008; after applying inclusion criteria, 3,888 procedures were analyzed. There was a strong correlation between PDR and WT by endoscopist (Pearson ρ = 0.64; p < 0.0001). PDR varied significantly by shift (morning 39.1%, mid-day 44.6%, and afternoon 38.9%; p = 0.01). PDR variation across DOW did not reach significance (range from 35.82% on Tuesday to 40.56% on Wednesday; p = 0.19). WT varied minimally and non-significantly by daily shift (p = 0.97) but significantly by DOW (p = 0.0006). Mean WT on the day with the shortest WT (Monday) was 7:26 (95% CI, 7:04 to 7:49), while the mean WT on the day with the longest WT (Friday) was 8:26 (95% CI, 8:04 to 8:49). DISCUSSION: Our data confirms the strong correlation between PDR and WT. However, unlike prior studies, PDR does not steadily decrease throughout the day with our 3-hour shift schedule. In fact, the highest PDR is during the mid-day shift. Also, WT is stable throughout the day. DOW analysis showed the reverse, with insignificant PDR and significant WT variation, with endoscopists spending an extra minute on average on Friday versus Monday. Other yet-identified factors likely contribute to variation in PDR.
M1066 Protocol Development for the Management of Button Battery-Induced Aortoesophageal Fistula in Children David Brumbaugh, Steven Colson, Sandoval A. John, Litovitz Toby, Kramer E. Robert Widespread use of higher-voltage lithium button batteries (BB) may place children at risk of more severe esophageal injury. Our institution recently experienced two pediatric deaths from aortoesophageal fistula (AEF) related hemorrhage due to esophageal BB impaction. We report the process and outcome in development of a multi-disciplinary, single-institution protocol that has led to our adoption of a new strategy for management of suspected AEF due to BB ingestion. In 1992, Litovitz et al. reported 2320 cases of BB ingestion from the National Button Battery Ingestion Hotline and Registry (NBBIHR), with no fatalities and two cases resulting in esophageal stenosis. Subsequently, there have been multiple case reports of deaths in children associated with ingestion of BB. Utilizing a literature search and the NBBIHR, we identified 12 BB-associated deaths, including seven fatal cases of pediatric AEF secondary to BB ingestion. Five cases have been reported since 2008. In four cases, the battery had been removed days or weeks prior to the development of GI bleeding. The majority of cases experienced a “sentinel bleed”, either hematemesis or melena, hours or days prior to the fatal hemorrhage event. In three cases, the child presented in extremis and did not respond to initial resuscitation efforts. In four cases, the child expired during surgical intervention. Existing literature on management of AEF in adults was also reviewed. Definitive management of AEF in adults requires surgical repair of the injured aorta, using synthetic or human grafts, and staged esophageal reconstruction, usually involving temporary esophageal diversion. Sengstaken-Blakemore tubes and, most recently, endovascular-placed aortic stents have provided temporary control of hemorrhage. Then, using one-on-one interviews with pediatric subspecialists from gastroenterology, general surgery, cardiothoracic surgery, cardiology, otolaryngology, intensive care, radiology, and emergency medicine, we explored strategies for care of suspected AEF secondary to BB ingestion in children. Utilizing a deliberative process, a management protocol was drafted for our institution that emphasizes a multidisciplinary approach to care, endoscopic surveillance after BB removal, and early recognition of AEF. Any GI bleeding will trigger immediate diagnostic and therapeutic strategies, culminating in emergent cardiothoracic surgical intervention in the case of a confirmed, or highly suspected, AEF. Anticipating a new era of severe esophageal injuries due to BB ingestion, the goal of this protocol is to intervene in patients with a “sentinel bleed” before a fatal hemorrhage event.
M1064 Queue Position in the Day's Endoscopic Schedule Impacts Effectiveness of Colonoscopy Alexander Lee, Nitin Gupta, John M. Iskander, Brian B. Borg, Gary R. Zuckerman, Bhaskar Banerjee, C. Prakash Gyawali BACKGROUND: Effectiveness of colonoscopy for colon cancer screening depends on polyp detection and removal. Later colonoscopy start time has recently been associated with reduced polyp detection, potentially from progressive operator fatigue. However, previous studies have not addressed the number of procedures preceding the colonoscopy of interest or adjusted for comorbid conditions. METHODS: Colonoscopies performed over a 4 month period at an academic medical center were eligible for inclusion. 24 endoscopists were scheduled for all day sessions. Completed outpatient colonoscopies (100% cecal intubation) were identified; comprehensive procedural data (including bowel preparation quality, sedation, procedure length, findings, complications) and clinical characteristics (including demographics, comorbidities, medications) were collected from chart review. Procedures were separated into 2 groups: AM (starting before 12 noon) and PM. Queue position (number of preceding endoscopic procedures) was recorded for each colonoscopy. Univariate and multivariate analyses were performed to identify if timing of the procedure predicted the finding of colon polyps. RESULTS: A total of 1100 colonoscopies on 1069 patients (mean age 58.0 ±0.4 yr, 59.5% female) fulfilled inclusion criteria. Of these, 711 procedures (64.6%) were done in AM. Indications consisted of screening (43.1%), surveillance (30.6%), occult or overt bleeding (13.9%), evaluation of symptoms (10.7%), and abnormalities on imaging studies (1.6%). Indications, comorbidities, body mass index, bowel preparation technique and quality, sedation, procedure length and trainee participation were not different between AM and PM procedures. AM procedures had a mean of 2.8 ±0.1 preceding endoscopic procedures, while PM procedures had 5.4 ±0.1. A mean of 1.0 ± 0.1 polyps were found per procedure; when averaged, detection rates did not differ between AM and PM. On multivariate regression analysis with backward elimination controlling for age, gender, indication, clinical comorbidities, bowel preparation, prior colonoscopy, endoscopist and medications, queue position independently predicted the mean number of detected polyps, which decreased by 5.3% for each successive queue position in the schedule through the day (p<0.001). Additionally, polyp detection decreased by 5.6% for each elapsed hour of the day (p=0.01). CONCLUSIONS: Both later colonoscopy start time and increasing number of preceding endoscopic procedures are associated with significantly fewer detected polyps. These results suggest that endoscopist fatigue later in the day may contribute to a decline in the effectiveness of colonoscopic polyp detection.
M1067 The use of Proton Pump Inhibitors and Clopidogrel in a District General Hospital Charles J. Butcher, Shamaila K. Butt, Louise Fuller, Maria Ifijen, Elizabeth Good, Niall M. van Someren, Kalpesh Besherdas Introduction Clopidogrel is an important anitiplatelet agent used to protect patients from acute coronary syndromes(ACS), cerebrovascular events (CVA) and prevent coronary stent thromboses . Patients receiving clopidogrel are commonly treated with proton pump inhibitors (PPIs) to protect from GI bleeding. Recent studies have sugessted PPIs (in particular omeprazole) which are inhibitors of cytochrome P-450, may decrease the efficacy of clopidogrel, which is metabolized to its active form by the same enzyme complex. Clinically, this is important, since the decrease in antiplatelet efficacy may be associated with an increased risk. Therefore, has been suggested that the concomitant use of PPI and clopidogrel be discouraged and other agents with no such interaction e.g. famotidine be used for GI protection. Aims To assess the reasons for concomitant use of PPIs and clopidogrel in our hospital. Methods A retrospective analysis of patients identified from May 09 to November 09 from the pharmacy JAC Medicines database with prescriptions of PPI and clopidogrel. Patients with PPI/clopidogrel therapy were scrutinised for indications of use, prescriber, and whether patients underwent foregut imaging to obtain accurate diagnosis prior to initiation of PPI. Results 36 patients who were on PPI therapy with clopidogrel were identified from the database. There were 24 females and mean age was 75 (41-96). Of these 33/36 (92%) patients had an acute coronary event of which 7/33 (21%) had a coronary stent inserted. 3/36 (8%) patients had a CVA as indication for clopidogrel. All 33/36 (92%) patients with a diagnosis of ACS had PPI therapy started by a cardiologist. The PPI of choice was omeprazole
M1065 Is Sigmoidoscopy Sufficient for Evaluating Inflammatory Status of Ulcerative Colitis Patients? Jun Kato, Motoaki Kuriyama, Sakiko Hiraoka, Eisuke Kaji, Toshio Uraoka, Reiji Higashi, Hideyuki Suzuki, Mitsuhiro Akita, Shunsuke Saito, Kazuhide Yamamoto Backgrounds: Although endoscopic examinations are necessary during the following-up of ulcerative colitis (UC) patients, it has not been clearly demonstrated to which colonic location the colonoscope should be inserted for precise evaluation of inflammation. Sigmoidoscopy may be sufficient. However, some UC patients harbor severer inflammation in the rightside of the colon. Aim: To determine adequate range of colonic observation to evaluate
AGA Abstracts
S-324
inflammation precisely in UC patients. Methods: Retrospective analysis of 545 total colonoscopic examinations for UC patients was performed. Severity of mucosal inflammation was evaluated using the Mayo score of endoscopic index at each location (rectum, sigmoid colon, descending colon, and the oral side of splenic flexure) in each UC patient. The colonic site with maximum inflammation in each patent was determined. If there are two or more colonic locations with the same maximum severity, the location nearest to the anal was used for analysis. In addition, if a patient has no inflammation (Mayo 0) throughout the colon, the rectum was evaluated as the location with maximum severity. Results: Of 545 patients, 314 (58%) have maximum inflammation in the rectum, 93 (17%) in the sigmoid colon, 55 (10%) in the descending colon, and 83 (15%) in the oral side of the splenic flexure. Namely, sigmoidoscopy is insufficient for 25% of UC patients for evaluating inflammation precisely. Patients were divided into two groups: those with maximum severity in the rectum or sigmoid colon (group I), and those with maximum severity in the descending colon or the oral side of splenic flexure (group II). The first-attack patients are significantly more frequently observed in the group II than in the group I (group I 6% vs. group II 17%, p < 0.0001). In addition, patients with no or mild inflammation (Mayo score = 0 or 1) in the rectum or sigmoid colon are more common in the group II than in the group I (group I 52% vs. group II 71%, p < 0.0001). Lastly, we analyzed 134 patients with no inflammation in the rectum and sigmoid colon. Among these patients, inflammatory mucosa in the descending colon or the oral side of the splenic flexure was observed in 54 (40%). Even in the 125 patients with clinically remission, 45 (36%) have inflammatory mucosa in the descending colon or the oral side of the splenic flexure. Conclusions: Sigmoidoscopy is not sufficient for evaluating inflammation precisely in UC patients. In particular, total colonoscopy is quite necessary in patients with first attack and in patients who have discrepancy between endoscopic features in the rectum or sigmoid colon and patient symptoms.
AGA Abstracts
Diurnal and Day-of-Week Variation in Polyp Detection Rate Gregory W. Munson, Dawn L. Francis INTRODUCTION: Colonoscopy reduces colon cancer risk by removing polyps. Research has shown that increased polyp detection rate (PDR) correlates with longer withdrawal time (WT), fellow assistance, and earlier time of day. It is unclear whether PDR varies by day of week (DOW). Mayo Clinic Rochester (MCR) schedules endoscopists for three 3-hour shifts daily. The current study examines daily shift and DOW variance in PDR at MCR and whether such variance correlates with WT. METHODS: Colonoscopies in 2008 with cecal intubation were identified in our endoscopy database. Inclusion criteria: (1) average-risk screening exams, (2) colon preparations graded fair adequate or better, (3) no fellow participation, and (4) performance by staff endoscopists with more than 100 colonoscopies in 2008. During exams, endoscopy nurses entered time stamps in the database to mark the proximal extent and end of each procedure; and WT is the difference for colonoscopies in which no polypectomy was performed. PDR is the number of colonoscopies with at least one polyp divided by total colonoscopies. PDR and WT by individual endoscopists were analyzed with Pearson's correlation (ρ). For daily shift and DOW, PDR was analyzed with chi-square (χ2), and one-way analysis of variation (ANOVA) was used to compare WT. Colorectal surgeons at MCR do not work standard 3-hour shifts and were excluded from shift analysis. RESULTS: There were 14,839 complete colonoscopies in the main MCR endoscopy unit in 2008; after applying inclusion criteria, 3,888 procedures were analyzed. There was a strong correlation between PDR and WT by endoscopist (Pearson ρ = 0.64; p < 0.0001). PDR varied significantly by shift (morning 39.1%, mid-day 44.6%, and afternoon 38.9%; p = 0.01). PDR variation across DOW did not reach significance (range from 35.82% on Tuesday to 40.56% on Wednesday; p = 0.19). WT varied minimally and non-significantly by daily shift (p = 0.97) but significantly by DOW (p = 0.0006). Mean WT on the day with the shortest WT (Monday) was 7:26 (95% CI, 7:04 to 7:49), while the mean WT on the day with the longest WT (Friday) was 8:26 (95% CI, 8:04 to 8:49). DISCUSSION: Our data confirms the strong correlation between PDR and WT. However, unlike prior studies, PDR does not steadily decrease throughout the day with our 3-hour shift schedule. In fact, the highest PDR is during the mid-day shift. Also, WT is stable throughout the day. DOW analysis showed the reverse, with insignificant PDR and significant WT variation, with endoscopists spending an extra minute on average on Friday versus Monday. Other yet-identified factors likely contribute to variation in PDR.
M1066 Protocol Development for the Management of Button Battery-Induced Aortoesophageal Fistula in Children David Brumbaugh, Steven Colson, Sandoval A. John, Litovitz Toby, Kramer E. Robert Widespread use of higher-voltage lithium button batteries (BB) may place children at risk of more severe esophageal injury. Our institution recently experienced two pediatric deaths from aortoesophageal fistula (AEF) related hemorrhage due to esophageal BB impaction. We report the process and outcome in development of a multi-disciplinary, single-institution protocol that has led to our adoption of a new strategy for management of suspected AEF due to BB ingestion. In 1992, Litovitz et al. reported 2320 cases of BB ingestion from the National Button Battery Ingestion Hotline and Registry (NBBIHR), with no fatalities and two cases resulting in esophageal stenosis. Subsequently, there have been multiple case reports of deaths in children associated with ingestion of BB. Utilizing a literature search and the NBBIHR, we identified 12 BB-associated deaths, including seven fatal cases of pediatric AEF secondary to BB ingestion. Five cases have been reported since 2008. In four cases, the battery had been removed days or weeks prior to the development of GI bleeding. The majority of cases experienced a “sentinel bleed”, either hematemesis or melena, hours or days prior to the fatal hemorrhage event. In three cases, the child presented in extremis and did not respond to initial resuscitation efforts. In four cases, the child expired during surgical intervention. Existing literature on management of AEF in adults was also reviewed. Definitive management of AEF in adults requires surgical repair of the injured aorta, using synthetic or human grafts, and staged esophageal reconstruction, usually involving temporary esophageal diversion. Sengstaken-Blakemore tubes and, most recently, endovascular-placed aortic stents have provided temporary control of hemorrhage. Then, using one-on-one interviews with pediatric subspecialists from gastroenterology, general surgery, cardiothoracic surgery, cardiology, otolaryngology, intensive care, radiology, and emergency medicine, we explored strategies for care of suspected AEF secondary to BB ingestion in children. Utilizing a deliberative process, a management protocol was drafted for our institution that emphasizes a multidisciplinary approach to care, endoscopic surveillance after BB removal, and early recognition of AEF. Any GI bleeding will trigger immediate diagnostic and therapeutic strategies, culminating in emergent cardiothoracic surgical intervention in the case of a confirmed, or highly suspected, AEF. Anticipating a new era of severe esophageal injuries due to BB ingestion, the goal of this protocol is to intervene in patients with a “sentinel bleed” before a fatal hemorrhage event.
M1064 Queue Position in the Day's Endoscopic Schedule Impacts Effectiveness of Colonoscopy Alexander Lee, Nitin Gupta, John M. Iskander, Brian B. Borg, Gary R. Zuckerman, Bhaskar Banerjee, C. Prakash Gyawali BACKGROUND: Effectiveness of colonoscopy for colon cancer screening depends on polyp detection and removal. Later colonoscopy start time has recently been associated with reduced polyp detection, potentially from progressive operator fatigue. However, previous studies have not addressed the number of procedures preceding the colonoscopy of interest or adjusted for comorbid conditions. METHODS: Colonoscopies performed over a 4 month period at an academic medical center were eligible for inclusion. 24 endoscopists were scheduled for all day sessions. Completed outpatient colonoscopies (100% cecal intubation) were identified; comprehensive procedural data (including bowel preparation quality, sedation, procedure length, findings, complications) and clinical characteristics (including demographics, comorbidities, medications) were collected from chart review. Procedures were separated into 2 groups: AM (starting before 12 noon) and PM. Queue position (number of preceding endoscopic procedures) was recorded for each colonoscopy. Univariate and multivariate analyses were performed to identify if timing of the procedure predicted the finding of colon polyps. RESULTS: A total of 1100 colonoscopies on 1069 patients (mean age 58.0 ±0.4 yr, 59.5% female) fulfilled inclusion criteria. Of these, 711 procedures (64.6%) were done in AM. Indications consisted of screening (43.1%), surveillance (30.6%), occult or overt bleeding (13.9%), evaluation of symptoms (10.7%), and abnormalities on imaging studies (1.6%). Indications, comorbidities, body mass index, bowel preparation technique and quality, sedation, procedure length and trainee participation were not different between AM and PM procedures. AM procedures had a mean of 2.8 ±0.1 preceding endoscopic procedures, while PM procedures had 5.4 ±0.1. A mean of 1.0 ± 0.1 polyps were found per procedure; when averaged, detection rates did not differ between AM and PM. On multivariate regression analysis with backward elimination controlling for age, gender, indication, clinical comorbidities, bowel preparation, prior colonoscopy, endoscopist and medications, queue position independently predicted the mean number of detected polyps, which decreased by 5.3% for each successive queue position in the schedule through the day (p<0.001). Additionally, polyp detection decreased by 5.6% for each elapsed hour of the day (p=0.01). CONCLUSIONS: Both later colonoscopy start time and increasing number of preceding endoscopic procedures are associated with significantly fewer detected polyps. These results suggest that endoscopist fatigue later in the day may contribute to a decline in the effectiveness of colonoscopic polyp detection.
M1067 The use of Proton Pump Inhibitors and Clopidogrel in a District General Hospital Charles J. Butcher, Shamaila K. Butt, Louise Fuller, Maria Ifijen, Elizabeth Good, Niall M. van Someren, Kalpesh Besherdas Introduction Clopidogrel is an important anitiplatelet agent used to protect patients from acute coronary syndromes(ACS), cerebrovascular events (CVA) and prevent coronary stent thromboses . Patients receiving clopidogrel are commonly treated with proton pump inhibitors (PPIs) to protect from GI bleeding. Recent studies have sugessted PPIs (in particular omeprazole) which are inhibitors of cytochrome P-450, may decrease the efficacy of clopidogrel, which is metabolized to its active form by the same enzyme complex. Clinically, this is important, since the decrease in antiplatelet efficacy may be associated with an increased risk. Therefore, has been suggested that the concomitant use of PPI and clopidogrel be discouraged and other agents with no such interaction e.g. famotidine be used for GI protection. Aims To assess the reasons for concomitant use of PPIs and clopidogrel in our hospital. Methods A retrospective analysis of patients identified from May 09 to November 09 from the pharmacy JAC Medicines database with prescriptions of PPI and clopidogrel. Patients with PPI/clopidogrel therapy were scrutinised for indications of use, prescriber, and whether patients underwent foregut imaging to obtain accurate diagnosis prior to initiation of PPI. Results 36 patients who were on PPI therapy with clopidogrel were identified from the database. There were 24 females and mean age was 75 (41-96). Of these 33/36 (92%) patients had an acute coronary event of which 7/33 (21%) had a coronary stent inserted. 3/36 (8%) patients had a CVA as indication for clopidogrel. All 33/36 (92%) patients with a diagnosis of ACS had PPI therapy started by a cardiologist. The PPI of choice was omeprazole
M1065 Is Sigmoidoscopy Sufficient for Evaluating Inflammatory Status of Ulcerative Colitis Patients? Jun Kato, Motoaki Kuriyama, Sakiko Hiraoka, Eisuke Kaji, Toshio Uraoka, Reiji Higashi, Hideyuki Suzuki, Mitsuhiro Akita, Shunsuke Saito, Kazuhide Yamamoto Backgrounds: Although endoscopic examinations are necessary during the following-up of ulcerative colitis (UC) patients, it has not been clearly demonstrated to which colonic location the colonoscope should be inserted for precise evaluation of inflammation. Sigmoidoscopy may be sufficient. However, some UC patients harbor severer inflammation in the rightside of the colon. Aim: To determine adequate range of colonic observation to evaluate
AGA Abstracts
S-324