- Email: [email protected]
M1090 Physician Practice Patterns May Influence Outcomes of Biliary Atresia
guidelines we intended to assess to what extent Austrian endoscopists are referring to the American directive. METHODS: Within the scope of the Austrian Society for Gastroenterology and Hepatology (ÖGGH) Project “certificate of quality for screening colonoscopy”, we collected data from 22.669 patients from 157 endoscopic units. According to the American guidelines follow-up colonoscopy should be scheduled based on the following criteria: several small hyperplastic polyps in 10 years, 1 to 2 small tubular adenomas (<1 cm) with low grade dysplasia (LGD) in 5 to 10 years, 3 to 10 adenomas >1cm or villous adenomas in 3 years, high grade dysplasia (HGD) adenomas and entire ablation in 3 years, more than 10 adenomas in 1 to 3 years and flat and broad based adenomas in 2 to 6 months. RESULTS: The 157 endoscopists recommend follow-up colonoscopies as follows: several small hyperplastic polyps: 3,3% of the participants recommend treatment after 10 years, whereas the majority (25,3%) carry out treatment after 5 to 10 years; 1 to 2 small tubular adenomas (<1 cm) with LGD: 16,8% recommend treatment after 5 years, the majority of 46,9% carry out treatment after 3 years; single adenoma >1cm or a villous adenoma: the majority of 27,3% are following the guideline (i.e. 3 years); HGD adenomas and entire ablation: the majority of 34% are following the guideline (i.e. 2-6 months). CONCLUSION: Austrian endoscopists are following the American guidelines in 17,7%. In Austria everything points to shortened intervals of follow-up colonoscopies compared to guidelines. Even though criteria like age, comorbidity, reduced visibility, compliance of the patient and family predisposition could lead to different recommendations. The American guidelines should be taken as a minimal standard to assure a high level of care.
M1087 Do DRG Hospital Reimbursements Reflect Fair Value?: the Gastroenterology Experience Gavin C. Harewood, Frank E. Murray, Stephen Patchett Introduction: Diagnosis Related Groups (DRGs) are diagnosis categories that classify hospital inpatients according to type and severity of illness. This classification is used by the Government to reimburse hospitals for provision of care. This study aimed to determine the appropriateness of DRG reimbursement by correlating DRG reimbursement with both patient level costs (PLC) and length of stay (LOS) for inpatients with Gastroenterology/Hepatology (GIH) diagnoses. Methods: All hospital inpatients admitted between January and December 2007 with the 14 most common GIH DRGs were identified. Patients whose hospital stay was prolonged for non-medical reasons (e.g., awaiting nursing home) were excluded. PLC comprised a weighted daily bed cost plus cost of medical services provided (e.g., radiology, pathology) calculated according to an activity-based costing approach; costs of medications were excluded. Ratios of DRG payment to both PLC (DRG/PLC) and LOS (DRG/LOS) were derived to assess over-/under-reimbursement. Results: Data on 341 hospital inpatients was reviewed. There was close correlation between DRG reimbursement and both PLC (r=0.74, p=0.003) and LOS (r=0.86, p<0.0001). Patients with non-complex GI hemorrhage, highly complex cirrhosis/alcoholic hepatitis and complex liver disease (non-cirrhotic/non-alcoholic) had disproportionately high DRG payments relative to LOS and PLC; complex GI hemorrhage, non-complex hepatobiliary/pancreatic malignancy and non-complex pancreatic disease (nonmalignant) had disproportionately low DRG payments (Table). Conclusion: Overall DRG reimbursement correlates closely with both PLC and LOS for inpatients with GIH diagnoses. However, DRG payments appear to either over- or under-reimburse for specific diagnoses. Future modification of DRG payments should take account of these imbalances.
M1089 Endoscopic Scale for Post Radiation Chronic Proctitis: Suggestion for Bleeding Management Alexandre Giraud, Anne Le Sidaner, Romain Legros, Virginie Valgueblasse, Antoine Bouygues, Francois Cessot, Denis Sautereau INTRODUCTION: Argon plasma coagulation treatment is one option in the management of bleeding post radiation chronic proctitis's. But when and how exactly using it ? Based on retrospective cases, we propose a new evaluation scale of endoscopic lesions and treatment option to optimise the argon procedure. AIMS & METHODS: Thirty four patients treated in our Endoscopic GI Unit were retrospectively included from 2002 to 2008. APC procedure was performed during colonoscopy after PEG upper preparation for each session. Each patient had a clinic and endoscopic follow up. RESULTS: Initial chutkan clinic's score was 3.1 and decreased to 0.57 after APC procedure. Hemoglobin rate was 1.7g/dL higher and no more blood transfusion was performed after APC management. Endoscopic's score improved 2.3 points (p<0.001) after endoscopic treatment. A mean of 2.6 APC sessions was required with a 48 W electrical power and a 0.75 L/mn gas flow average. A 40 W power and 0.6 L/mn flow parameters, coagulate bleeding vessels and limit ulcerative complications and microrecty. Whereas using a flow > 0.8L/mn or a power > 50W increase significantly complications rate without better APC efficiency. No infectious complication occurs with or without antibiotherapy. APC is efficient for post radiation chronic proctitis. Mostly APC allows every grade lesion's treatment by spotting or painting application even on sus-anal bleeding. CONCLUSION: Up to these result we suggest a new post radiation proctitis's endoscopic lesion scale and an optimal way of treatment with APC. Stage 0 is a normal mucosal aspect, no treatment is required. Stage 1 is small telangiectasia without any bleeding, treatment is medical firstly. Stage 2 corresponds to a neovascularisation, telangiectasia are organized as a mesh, best treatment should be an endoscopic APC spotting. Stage 3 is mucosal bleeding on contact, it's management is APC (spotting or painting). Same treatment for stage 4 corresponding to spontaneous bleeding's area. Diffuse bleeding is Stage 5 first treatment might be APC (painting) but formaline is also possible, at least oxygen therapy can be proposed. Stage 6, ulcers are treated by APC or Formaline except on the ulcer itself or by oxygen therapy. M1090 Physician Practice Patterns May Influence Outcomes of Biliary Atresia Joseph Palermo, Shannon Joerger, Peter Putnam, Jane Garbutt Objective: Outcomes for biliary atresia (BA) are improved if diagnosis and surgery occur before 2 months of age, yet the average time to diagnosis in the U.S. is over 60 days. We hypothesize that primary care management of neonatal jaundice does not follow the current published recommendation to identify cholestatic neonates by obtaining a fractionated bilirubin (conjugated or direct) if there is persistent jaundice at 3 weeks of age. We sought to describe current practice patterns in order to identify roadblocks to early diagnosis of BA and develop systems-based strategies to optimize management of cholestatic neonates. Methods: An anonymous 29-item survey was mailed to community pediatricians in St Louis, Missouri between July and October 2009. The survey addressed practice demographics, routine newborn office visits and the management of neonatal jaundice. Results: A total of 108/240 (45%) of eligible physicians responded (mean years in practice, 15.3, SD, 9.4; 37% male). Only 49% and 16% of respondents, respectively, were very familiar with the AAP recommendations on management of newborn hyperbilirubinemia or management of prolonged neonatal jaundice. Eighty-six percent of physicians reported all newborns were checked with transcutaneous bilirubin (TcB) prior to hospital discharge. Physicians were more likely to use TcB than total serum bilirubin or fractionated bilirubin to reassess a newborn with initial TcB readings below 10mg/dL. For breastfed or bottle fed newborns, respectively, 37% and 58% of physicians reported only a single office visit by 3 weeks of age, usually within 72 hours of hospital discharge. Three percent and 15% of physicians reported that breastfed or bottle fed newborns, respectively, will still not have had a second office visit at one month. Ninety-two percent of physicians routinely obtain a fractionated bilirubin on infants jaundiced at or beyond 4 weeks of age. The most common reason not to obtain a fractionated bilirubin was that the infant is breastfed. For a cholestatic infant identified beyond 4 weeks of age, 32% of respondents would not immediately refer to a pediatric gastroenterologist but instead obtain additional testing. Conclusions: Efficient management of neonatal cholestasis is hindered by lack of knowledge of current recommendations, frequent use of TcB to monitor mild jaundice, a routine care schedule that limits opportunities to assess infants with prolonged mild jaundice who are otherwise well, and
* adjusted ratio with ‘Non-malignant disorder of pancreas, non-complex' as reference 1.0 M1088 Follow-up Colonoscopy in Austria and the American Guidelines: A Comparison Orsolya Gal, Caspar Wiener, Karoline G. Reinhart, Michaela Hassler, Sibylle Pramhas, Werner H. Weiss, Monika Ferlitsch INTRODUCTION: If in the process of a basic colonoscopy adenomas were found, the risk of developing new ones is high. Hence, the patients need an accurate follow-up colonoscopy after polypectomy of adenomas. The American guidelines, published in 2008 (American Cancer Society; Gastroenterology 2008;134:1570-1595), established a set of terms to define an interval of follow-up colonoscopy based on the numbers and size of adenomas found and their corresponding histological characteristics. Given that in Austria are no published
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frequent indications were:low gastrointestinal bleeding 126(27%),previous polypectomy 68(15%),screening 65(14%),constipation 59(13%),surgery of previous colon cancer 40(9%),iron deficiency anemia 32(7%) and others in 76(17%).Indications were classified as appropriate in 370 cases(79%),inappropriate in 10(2%) and doubtful in 86 (19%).Positive endoscopic findings were reported in 172(37%) patients,out of which 145(84%) were with appropriate indication, 2(1%) with inappropriate indication and 25 (14%) with doubtful indication(p=0,11)There were no statistically significant differences among the different specialities of the referring physicians. CONCLUSIONS:This study showed a significant frequency of appropriate indication for colonoscopy according to ASGE guidelines regardless of the referring physicians.There was a higher percentage of relevant findings in those with appropriate indication.The mean age of patients with significant endoscopic findings were higher than those without endoscopic findings.
a delay in subspecialist referral once cholestasis is identified. This study suggests that a more uniform approach to the management of prolonged neonatal jaundice is needed to expedite the diagnosis of BA.
(IGFBP1) and insulin growth factor binding protein-3 (IGFBP3) were measured in 45 nondysplastic, 8 low grade dysplasia (LGD), 14 high grade dysplasia (HGD), and 9 EAC subjects. Insulin resistance was estimated through homeostatic model assessment (HOMA). Body mass index (BMI) and waist-hip ratio were calculated. Immunohistochemistry (IHC) was performed on paraffin embedded tissue derived from BE cases using rabbit monoclonal antibodies to p-mTOR and p-AKT, mouse monoclonal antibody to Ki-67, and rabbit polyclonal antibody to p-IRS1. IHC results were reviewed by an expert pathologist blinded to patient's BMI and results of systemic serum assays. Intensity of staining was classified as weak or strong. Chi-square and Fisher's exact tests were used to assess differences in staining intensity across all variables of interest. Strength of association between p-IRS1 and p-AKT, p-mTOR, and Ki-67 was measured by Spearman correlation coefficient. RESULTS: Eighteen of 38 (47%) BE, 4/8 (50%) LGD, 10/14 (71%) HGD, and 7/9 (78%) EAC cases showed strong staining for p-IRS1. A significantly higher proportion of HGD/EAC subjects showed p-IRS1 staining when compared to BE/LGD subjects, 48% vs. 74%, p < 0.05. p-IRS1 immunostaining was highly correlated with strong immunostaining of the downstream mediators p-AKT and p-mTOR (Spearman correlation coefficient = 0.60 for p-IRS1/p-AKT and p-IRS1/p-mTOR, p < 0.01) and the proliferation marker Ki-67 (Spearman correlation coefficient=0.47, p=0.02). Systemic levels of insulin, IGF-1, or IGF-2 were not associated with tissue immunostaining of p-IRS1. CONCLUSIONS: Activation of the insulin/IGF pathway in BE is associated with cellular proliferation and appears to play a role in the progression from metaplasia to cancer. Activation of the insulin/IGF pathway at the tissue level is likely complex and does not have a simple association with systemic measures of insulin or IGF.
AGA Abstracts
M1091 Is There a Way to Implement Guidelines Into Clinical Practice? Wolfgang Kruis Aim: It has been described that adherence to treatment guidelines is limited and a wide variability exists regarding prescription of standard drugs such as mesalazine for ulcerative colitis (UC). The effectiveness of measures for implementation of new therapeutic standards is unclear. The aim of this project was to analyse previous therapeutic management in UC outpatients and to observe the influence of a simple strategy such as systematic documentation on prescription behaviour. Materials and methods: Medication was prescribed at the discretion of the participating gastroenterologists. Mesalazine treatment of UC patients was prospectively and systematically documented in 107 private gastroenterology practices between 9/2007 and 7/2008. Data management and statistical analysis were performed externally. Results: Complete data were obtained from a total of 360 UC patients (median age 43 yrs, 14-83 yrs; 49.2% females). 203/360 patients (56.3%) had active UC. 35% of these patients were newly diagnosed; 29% were known to have UC, but had been without any maintenance treatment, while 36% were on maintenance therapy before flaring (72.6% oral mesalazine, 24.7% rectal mesalazine, 32.9% steroids, 20.5% azathioprine [multiple entries]). The acute flare was treated with oral mesalazine alone in 70% (median dose 3.0 g/d [1.5-5.0 g/d]) and with oral/rectal mesalazine combination therapy in 30% (median rectal dose 1.6 g/d [0.25-10.0 g/d]). Patients received mesalazine in 1-4 doses per day. Granule preparations were taken mostly twice daily, tablets three times per day. Once daily dosing was recommended in 6% of the new prescriptions at baseline (10/2007). This percentage increased to 47% after 8 months. 157/360 of the documented patients (43.7%) were in remission. Maintenance treatment comprised oral mesalazine alone in 88% of the patients (median dose 2.1g/d [1.04.0 g/d]) and oral/rectal mesalazine combination in 12% (median rectal dose 0.8g/d [0.252.0 g/d]). Once daily dosing was recommended in 17% of the new prescriptions at baseline (10/2007), this percentage increased to 58% after 8 months. 20% of participating gastroenterologists reported basing their treatment decision on relevant new study data. Conclusion: In this prospective observational study, mesalazine was used in a patient-personalized approach and, moreover, in contrast to previous publications, for the most part according to guidelines. New study results were rapidly implemented into daily treatment decisions. A simple measure such as systematic documentation may have significant beneficial effects on treatment quality.
M1094 Meta-Analysis of the Association of Gastroesophageal Reflux Disease With Barrett's Esophagus: NO Association With Short Segment Barrett's Esophagus Justin B. Taylor, Joel H. Rubenstein Background: Esophageal adenocarcinoma is associated with Barrett's esophagus (BE), a metaplastic change thought to be due to gastroesophageal reflux disease (GERD). Current preventive efforts rely on screening of individuals with GERD symptoms. However, some recent studies have found a high prevalence of BE in patients without GERD, and others have found little or no association with GERD. We hypothesized that high quality study designs show less association of GERD with BE, and that GERD is only weakly associated with short segment BE. Methods: We performed a systematic literature search in multiple online electronic databases regardless of language. Eligible studies required visualization of columnar mucosa and histologic confirmation of intestinal metaplasia, and GERD symptoms ascertained by questionnaire or interview. The highest quality design was defined a priori by both cases and controls identified among unselected research volunteers (“research design”) rather than by patients selected for endoscopy for clinical indications (“clinical design”) which introduces selection and ascertainment bias. A priori, heterogeneity was defined by Cochrane's Q p < 0.20, and Inconsistency Index, I2 (25% low, 50% moderate, 75% high). Results: Systematic review identified 13,392 citations, and 108 articles were reviewed, resulting in 26 studies meeting eligibility. The summary odds ratio (OR) for the association of GERD with BE from all studies was 3.41 (95% CI 3.09-3.76), but the results were very heterogeneous (p = 0.0001; I2 = 87%). When stratified by BE length and sampling design, the studies with clinical design demonstrated substantial, but heterogeneous, association with short segment BE (OR = 1.96, 95% CI=1.35-2.84; p = 0.02; I2 = 60%) and greater and homogeneous association with long segment BE (OR = 2.96; 95% CI 1.69-5.19; p = 0.25; I2 = 25%). In the research design, stratifying by length of BE resolved the heterogeneity and demonstrated a strong association with long segment BE (OR = 4.92; 95% CI 2.01-12.0; p = 0.30; I2 = 19%) but no association with short segment BE (OR = 1.15; 95% CI 0.764-1.73; p = 0.84; I2 = 0%). Funnel plots demonstrated evidence for bias against publication of small negative studies. Conclusions: In the highest quality studies, GERD symptoms are not associated with short segment BE, but increase the odds of long segment BE by 5-fold. GERD symptoms can serve as a reliable predictor of long segment BE, but not short segment BE. If short segment BE is considered worthy of identification, then current screening practices do not select patients at risk for endoscopy, and other methods of selection for screening need to be developed.
M1092 Typical Gastroesophageal Reflux Disease: Just Heartburn and Regurgitation? Fermin Mearin, Julio Ponce, Marta Ponce, Agustín Balboa, Miguel A. Gonzalez, Javier Zapardiel Heartburn and regurgitation are considered to be the typical gastroesophageal reflux disease (GERD) symptoms but in many patients other symptoms coexist. Aim: To evaluate the association among dyspeptic and supraesophageal symptoms with typical GERD symptoms, and to investigate its repercussion in quality of life and therapeutic response. Methods: We conducted a prospective, multicentre, observational study that included 301 patients attended in gastroenterology offices for typical GERD symptoms (heartburn and/or regurgitation). A directed interview was performed to identify upper digestive symptoms. Symptoms severity were quantified by specific symptom scores and visual analogue scales. Quality of life was evaluated by two different questionnaires (SF-12 and QoLRAD). Patients were treated with proton pump inhibitors (PPI) according to the Spanish Association Gastroenterology clinical practice guideline recommendations. Results: 99% of the patients complained of heartburn (78% nocturnal heartburn), 86% of regurgitation and 85% of both; 1% only suffered regurgitation. Dyspeptic symptoms were associated in 91% of the cases and supraesophageal symptoms in 58%. The symptoms were severe/extremely severe in 56% for heartburn, 35% for regurgitation and 34% for nocturnal heartburn. One in every 6 patients had dysphagia: 14% of them severe/extremely severe. 52% of the patients chose heartburn as the most bothersome symptom, 20% thoracic pain, 8% regurgitation, 6% epigastric pain and 3% nocturnal heartburn. Thus, the most bothersome symptom was a typical one from GERD in 64%, a supraesophageal one in 23% or a dyspeptic one in 10%. Presence of supraesophageal and/or dyspeptic symptoms was associated with worse quality of life (according to SF-12 and QoLRAD). After treatment 93% of the patients had not heartburn and 87% not regurgitation. Response rate was significantly higher (p<0.05) in patients with nocturnal heartburn (96% vs 86%) or regurgitation (95% vs 83%), whereas the association of supraesophageal or dyspeptic symptoms did not influence. Conclusions: The association of supraesophageal and/or dyspeptic symptoms in patients with typical GERD symptoms that were attended in gastroenterology offices is extremely frequent and worsens quality of life. However, therapeutic response PPI treatment is not modified by its coexistence.
M1095 Optical Analysis of Squamous Cells Predicts the Presence of Esophageal Dysplasia and Adenocarcinoma via Partial-Wave Spectroscopic Microscopy Yang Liu, Kevin McGrath, Rajan K. Bista, Julie Holinga, Kevin D. Staton, Kenneth E. Fasanella, Randall Brand Introduction: Common surveillance methodology for Barrett's esophagus (BE) includes fourquadrant, random biopsies every 1-2 cm from the entire length of Barrett's mucosa to identify dysplasia or adenocarcinoma. However, random biopsies are fraught with sampling error, low detection rate for high-grade dysplasia, and unnecessary biopsies. A more practical approach utilizing the concept of a field effect would be to identify patients at risk of developing adenocarcinoma simply by analyzing normal appearing squamous cells from the esophagus. A novel optical technology - partial-wave spectroscopic microscopy (PWS) allows quantitative assessment of subtle structural alterations within single cell and sub-cellular structures with unprecedented sensitivity. We hypothesize that the squamous cells from normal-appearing esophageal epithelium would exhibit subtle structural changes that are detectable by PWS, which would allow the discrimination between those BE patients with adenocarcinoma and dysplasia and those patients without. Methods: A pilot study with 19 patients undergoing scheduled upper endoscopy: 3 controls without BE, 3 with BE with no dysplasia, 2 with BE and low-grade dysplasia (LGD), 5 with BE and high-grade dysplasia (HGD) and 6 BE with adenocarcinoma. We obtained squamous cells from normal appearing esophagus at 20 cm. The cells were fixed with Cytolyt® and subsequently prepared with Thinprep®. PWS analysis was done by observers blinded to clinical/endoscopic data. Patients were categorized into two groups: controls/BE without dysplasia and adenocarcinoma/HGD/ LGD. Results: Several PWS markers (disorder strength, standard deviation of disorder strength, correlation decay, phase, standard deviation of phase) that were statistically significant in discriminating the adenocarcinoma/dysplasia group were identified. A prediction
M1093 Insulin/Insulin Like Growth Factor-1 Pathway in Barrett's Carcinogenesis Katarina B. Greer, Lacie Brenner, Beth Bednarchik, Dawn Dawson, Li Li, Amitabh Chak, Joseph Willis BACKGROUND: Obesity associated carcinogenesis is postulated to be mediated through the proliferative actions of insulin and the insulin like growth factor (IGF) family. The phosphorylation of insulin receptor substrate-1 (pIRS-1) is the first step when insulin and/ or IGF-1 bind to their tyrosine kinase receptors. pIRS1 activates downstream mediators — phosphorylated m-TOR (p-mTOR) and phosphorylated-AKT (p-AKT). The aim of this study was to determine whether the insulin/IGF-1pathway is involved in the sequential progression from Barrett's esophagus (BE) to dysplasia to esophageal adenocarcinoma (EAC). METHODS: Fasting serum levels of insulin, glucose, IGF-1, insulin growth factor binding protein-1
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M1087 Do DRG Hospital Reimbursements Reflect Fair Value?: the Gastroenterology Experience Gavin C. Harewood, Frank E. Murray, Stephen Patchett Introduction: Diagnosis Related Groups (DRGs) are diagnosis categories that classify hospital inpatients according to type and severity of illness. This classification is used by the Government to reimburse hospitals for provision of care. This study aimed to determine the appropriateness of DRG reimbursement by correlating DRG reimbursement with both patient level costs (PLC) and length of stay (LOS) for inpatients with Gastroenterology/Hepatology (GIH) diagnoses. Methods: All hospital inpatients admitted between January and December 2007 with the 14 most common GIH DRGs were identified. Patients whose hospital stay was prolonged for non-medical reasons (e.g., awaiting nursing home) were excluded. PLC comprised a weighted daily bed cost plus cost of medical services provided (e.g., radiology, pathology) calculated according to an activity-based costing approach; costs of medications were excluded. Ratios of DRG payment to both PLC (DRG/PLC) and LOS (DRG/LOS) were derived to assess over-/under-reimbursement. Results: Data on 341 hospital inpatients was reviewed. There was close correlation between DRG reimbursement and both PLC (r=0.74, p=0.003) and LOS (r=0.86, p<0.0001). Patients with non-complex GI hemorrhage, highly complex cirrhosis/alcoholic hepatitis and complex liver disease (non-cirrhotic/non-alcoholic) had disproportionately high DRG payments relative to LOS and PLC; complex GI hemorrhage, non-complex hepatobiliary/pancreatic malignancy and non-complex pancreatic disease (nonmalignant) had disproportionately low DRG payments (Table). Conclusion: Overall DRG reimbursement correlates closely with both PLC and LOS for inpatients with GIH diagnoses. However, DRG payments appear to either over- or under-reimburse for specific diagnoses. Future modification of DRG payments should take account of these imbalances.
M1089 Endoscopic Scale for Post Radiation Chronic Proctitis: Suggestion for Bleeding Management Alexandre Giraud, Anne Le Sidaner, Romain Legros, Virginie Valgueblasse, Antoine Bouygues, Francois Cessot, Denis Sautereau INTRODUCTION: Argon plasma coagulation treatment is one option in the management of bleeding post radiation chronic proctitis's. But when and how exactly using it ? Based on retrospective cases, we propose a new evaluation scale of endoscopic lesions and treatment option to optimise the argon procedure. AIMS & METHODS: Thirty four patients treated in our Endoscopic GI Unit were retrospectively included from 2002 to 2008. APC procedure was performed during colonoscopy after PEG upper preparation for each session. Each patient had a clinic and endoscopic follow up. RESULTS: Initial chutkan clinic's score was 3.1 and decreased to 0.57 after APC procedure. Hemoglobin rate was 1.7g/dL higher and no more blood transfusion was performed after APC management. Endoscopic's score improved 2.3 points (p<0.001) after endoscopic treatment. A mean of 2.6 APC sessions was required with a 48 W electrical power and a 0.75 L/mn gas flow average. A 40 W power and 0.6 L/mn flow parameters, coagulate bleeding vessels and limit ulcerative complications and microrecty. Whereas using a flow > 0.8L/mn or a power > 50W increase significantly complications rate without better APC efficiency. No infectious complication occurs with or without antibiotherapy. APC is efficient for post radiation chronic proctitis. Mostly APC allows every grade lesion's treatment by spotting or painting application even on sus-anal bleeding. CONCLUSION: Up to these result we suggest a new post radiation proctitis's endoscopic lesion scale and an optimal way of treatment with APC. Stage 0 is a normal mucosal aspect, no treatment is required. Stage 1 is small telangiectasia without any bleeding, treatment is medical firstly. Stage 2 corresponds to a neovascularisation, telangiectasia are organized as a mesh, best treatment should be an endoscopic APC spotting. Stage 3 is mucosal bleeding on contact, it's management is APC (spotting or painting). Same treatment for stage 4 corresponding to spontaneous bleeding's area. Diffuse bleeding is Stage 5 first treatment might be APC (painting) but formaline is also possible, at least oxygen therapy can be proposed. Stage 6, ulcers are treated by APC or Formaline except on the ulcer itself or by oxygen therapy. M1090 Physician Practice Patterns May Influence Outcomes of Biliary Atresia Joseph Palermo, Shannon Joerger, Peter Putnam, Jane Garbutt Objective: Outcomes for biliary atresia (BA) are improved if diagnosis and surgery occur before 2 months of age, yet the average time to diagnosis in the U.S. is over 60 days. We hypothesize that primary care management of neonatal jaundice does not follow the current published recommendation to identify cholestatic neonates by obtaining a fractionated bilirubin (conjugated or direct) if there is persistent jaundice at 3 weeks of age. We sought to describe current practice patterns in order to identify roadblocks to early diagnosis of BA and develop systems-based strategies to optimize management of cholestatic neonates. Methods: An anonymous 29-item survey was mailed to community pediatricians in St Louis, Missouri between July and October 2009. The survey addressed practice demographics, routine newborn office visits and the management of neonatal jaundice. Results: A total of 108/240 (45%) of eligible physicians responded (mean years in practice, 15.3, SD, 9.4; 37% male). Only 49% and 16% of respondents, respectively, were very familiar with the AAP recommendations on management of newborn hyperbilirubinemia or management of prolonged neonatal jaundice. Eighty-six percent of physicians reported all newborns were checked with transcutaneous bilirubin (TcB) prior to hospital discharge. Physicians were more likely to use TcB than total serum bilirubin or fractionated bilirubin to reassess a newborn with initial TcB readings below 10mg/dL. For breastfed or bottle fed newborns, respectively, 37% and 58% of physicians reported only a single office visit by 3 weeks of age, usually within 72 hours of hospital discharge. Three percent and 15% of physicians reported that breastfed or bottle fed newborns, respectively, will still not have had a second office visit at one month. Ninety-two percent of physicians routinely obtain a fractionated bilirubin on infants jaundiced at or beyond 4 weeks of age. The most common reason not to obtain a fractionated bilirubin was that the infant is breastfed. For a cholestatic infant identified beyond 4 weeks of age, 32% of respondents would not immediately refer to a pediatric gastroenterologist but instead obtain additional testing. Conclusions: Efficient management of neonatal cholestasis is hindered by lack of knowledge of current recommendations, frequent use of TcB to monitor mild jaundice, a routine care schedule that limits opportunities to assess infants with prolonged mild jaundice who are otherwise well, and
* adjusted ratio with ‘Non-malignant disorder of pancreas, non-complex' as reference 1.0 M1088 Follow-up Colonoscopy in Austria and the American Guidelines: A Comparison Orsolya Gal, Caspar Wiener, Karoline G. Reinhart, Michaela Hassler, Sibylle Pramhas, Werner H. Weiss, Monika Ferlitsch INTRODUCTION: If in the process of a basic colonoscopy adenomas were found, the risk of developing new ones is high. Hence, the patients need an accurate follow-up colonoscopy after polypectomy of adenomas. The American guidelines, published in 2008 (American Cancer Society; Gastroenterology 2008;134:1570-1595), established a set of terms to define an interval of follow-up colonoscopy based on the numbers and size of adenomas found and their corresponding histological characteristics. Given that in Austria are no published
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AGA Abstracts
frequent indications were:low gastrointestinal bleeding 126(27%),previous polypectomy 68(15%),screening 65(14%),constipation 59(13%),surgery of previous colon cancer 40(9%),iron deficiency anemia 32(7%) and others in 76(17%).Indications were classified as appropriate in 370 cases(79%),inappropriate in 10(2%) and doubtful in 86 (19%).Positive endoscopic findings were reported in 172(37%) patients,out of which 145(84%) were with appropriate indication, 2(1%) with inappropriate indication and 25 (14%) with doubtful indication(p=0,11)There were no statistically significant differences among the different specialities of the referring physicians. CONCLUSIONS:This study showed a significant frequency of appropriate indication for colonoscopy according to ASGE guidelines regardless of the referring physicians.There was a higher percentage of relevant findings in those with appropriate indication.The mean age of patients with significant endoscopic findings were higher than those without endoscopic findings.
a delay in subspecialist referral once cholestasis is identified. This study suggests that a more uniform approach to the management of prolonged neonatal jaundice is needed to expedite the diagnosis of BA.
(IGFBP1) and insulin growth factor binding protein-3 (IGFBP3) were measured in 45 nondysplastic, 8 low grade dysplasia (LGD), 14 high grade dysplasia (HGD), and 9 EAC subjects. Insulin resistance was estimated through homeostatic model assessment (HOMA). Body mass index (BMI) and waist-hip ratio were calculated. Immunohistochemistry (IHC) was performed on paraffin embedded tissue derived from BE cases using rabbit monoclonal antibodies to p-mTOR and p-AKT, mouse monoclonal antibody to Ki-67, and rabbit polyclonal antibody to p-IRS1. IHC results were reviewed by an expert pathologist blinded to patient's BMI and results of systemic serum assays. Intensity of staining was classified as weak or strong. Chi-square and Fisher's exact tests were used to assess differences in staining intensity across all variables of interest. Strength of association between p-IRS1 and p-AKT, p-mTOR, and Ki-67 was measured by Spearman correlation coefficient. RESULTS: Eighteen of 38 (47%) BE, 4/8 (50%) LGD, 10/14 (71%) HGD, and 7/9 (78%) EAC cases showed strong staining for p-IRS1. A significantly higher proportion of HGD/EAC subjects showed p-IRS1 staining when compared to BE/LGD subjects, 48% vs. 74%, p < 0.05. p-IRS1 immunostaining was highly correlated with strong immunostaining of the downstream mediators p-AKT and p-mTOR (Spearman correlation coefficient = 0.60 for p-IRS1/p-AKT and p-IRS1/p-mTOR, p < 0.01) and the proliferation marker Ki-67 (Spearman correlation coefficient=0.47, p=0.02). Systemic levels of insulin, IGF-1, or IGF-2 were not associated with tissue immunostaining of p-IRS1. CONCLUSIONS: Activation of the insulin/IGF pathway in BE is associated with cellular proliferation and appears to play a role in the progression from metaplasia to cancer. Activation of the insulin/IGF pathway at the tissue level is likely complex and does not have a simple association with systemic measures of insulin or IGF.
AGA Abstracts
M1091 Is There a Way to Implement Guidelines Into Clinical Practice? Wolfgang Kruis Aim: It has been described that adherence to treatment guidelines is limited and a wide variability exists regarding prescription of standard drugs such as mesalazine for ulcerative colitis (UC). The effectiveness of measures for implementation of new therapeutic standards is unclear. The aim of this project was to analyse previous therapeutic management in UC outpatients and to observe the influence of a simple strategy such as systematic documentation on prescription behaviour. Materials and methods: Medication was prescribed at the discretion of the participating gastroenterologists. Mesalazine treatment of UC patients was prospectively and systematically documented in 107 private gastroenterology practices between 9/2007 and 7/2008. Data management and statistical analysis were performed externally. Results: Complete data were obtained from a total of 360 UC patients (median age 43 yrs, 14-83 yrs; 49.2% females). 203/360 patients (56.3%) had active UC. 35% of these patients were newly diagnosed; 29% were known to have UC, but had been without any maintenance treatment, while 36% were on maintenance therapy before flaring (72.6% oral mesalazine, 24.7% rectal mesalazine, 32.9% steroids, 20.5% azathioprine [multiple entries]). The acute flare was treated with oral mesalazine alone in 70% (median dose 3.0 g/d [1.5-5.0 g/d]) and with oral/rectal mesalazine combination therapy in 30% (median rectal dose 1.6 g/d [0.25-10.0 g/d]). Patients received mesalazine in 1-4 doses per day. Granule preparations were taken mostly twice daily, tablets three times per day. Once daily dosing was recommended in 6% of the new prescriptions at baseline (10/2007). This percentage increased to 47% after 8 months. 157/360 of the documented patients (43.7%) were in remission. Maintenance treatment comprised oral mesalazine alone in 88% of the patients (median dose 2.1g/d [1.04.0 g/d]) and oral/rectal mesalazine combination in 12% (median rectal dose 0.8g/d [0.252.0 g/d]). Once daily dosing was recommended in 17% of the new prescriptions at baseline (10/2007), this percentage increased to 58% after 8 months. 20% of participating gastroenterologists reported basing their treatment decision on relevant new study data. Conclusion: In this prospective observational study, mesalazine was used in a patient-personalized approach and, moreover, in contrast to previous publications, for the most part according to guidelines. New study results were rapidly implemented into daily treatment decisions. A simple measure such as systematic documentation may have significant beneficial effects on treatment quality.
M1094 Meta-Analysis of the Association of Gastroesophageal Reflux Disease With Barrett's Esophagus: NO Association With Short Segment Barrett's Esophagus Justin B. Taylor, Joel H. Rubenstein Background: Esophageal adenocarcinoma is associated with Barrett's esophagus (BE), a metaplastic change thought to be due to gastroesophageal reflux disease (GERD). Current preventive efforts rely on screening of individuals with GERD symptoms. However, some recent studies have found a high prevalence of BE in patients without GERD, and others have found little or no association with GERD. We hypothesized that high quality study designs show less association of GERD with BE, and that GERD is only weakly associated with short segment BE. Methods: We performed a systematic literature search in multiple online electronic databases regardless of language. Eligible studies required visualization of columnar mucosa and histologic confirmation of intestinal metaplasia, and GERD symptoms ascertained by questionnaire or interview. The highest quality design was defined a priori by both cases and controls identified among unselected research volunteers (“research design”) rather than by patients selected for endoscopy for clinical indications (“clinical design”) which introduces selection and ascertainment bias. A priori, heterogeneity was defined by Cochrane's Q p < 0.20, and Inconsistency Index, I2 (25% low, 50% moderate, 75% high). Results: Systematic review identified 13,392 citations, and 108 articles were reviewed, resulting in 26 studies meeting eligibility. The summary odds ratio (OR) for the association of GERD with BE from all studies was 3.41 (95% CI 3.09-3.76), but the results were very heterogeneous (p = 0.0001; I2 = 87%). When stratified by BE length and sampling design, the studies with clinical design demonstrated substantial, but heterogeneous, association with short segment BE (OR = 1.96, 95% CI=1.35-2.84; p = 0.02; I2 = 60%) and greater and homogeneous association with long segment BE (OR = 2.96; 95% CI 1.69-5.19; p = 0.25; I2 = 25%). In the research design, stratifying by length of BE resolved the heterogeneity and demonstrated a strong association with long segment BE (OR = 4.92; 95% CI 2.01-12.0; p = 0.30; I2 = 19%) but no association with short segment BE (OR = 1.15; 95% CI 0.764-1.73; p = 0.84; I2 = 0%). Funnel plots demonstrated evidence for bias against publication of small negative studies. Conclusions: In the highest quality studies, GERD symptoms are not associated with short segment BE, but increase the odds of long segment BE by 5-fold. GERD symptoms can serve as a reliable predictor of long segment BE, but not short segment BE. If short segment BE is considered worthy of identification, then current screening practices do not select patients at risk for endoscopy, and other methods of selection for screening need to be developed.
M1092 Typical Gastroesophageal Reflux Disease: Just Heartburn and Regurgitation? Fermin Mearin, Julio Ponce, Marta Ponce, Agustín Balboa, Miguel A. Gonzalez, Javier Zapardiel Heartburn and regurgitation are considered to be the typical gastroesophageal reflux disease (GERD) symptoms but in many patients other symptoms coexist. Aim: To evaluate the association among dyspeptic and supraesophageal symptoms with typical GERD symptoms, and to investigate its repercussion in quality of life and therapeutic response. Methods: We conducted a prospective, multicentre, observational study that included 301 patients attended in gastroenterology offices for typical GERD symptoms (heartburn and/or regurgitation). A directed interview was performed to identify upper digestive symptoms. Symptoms severity were quantified by specific symptom scores and visual analogue scales. Quality of life was evaluated by two different questionnaires (SF-12 and QoLRAD). Patients were treated with proton pump inhibitors (PPI) according to the Spanish Association Gastroenterology clinical practice guideline recommendations. Results: 99% of the patients complained of heartburn (78% nocturnal heartburn), 86% of regurgitation and 85% of both; 1% only suffered regurgitation. Dyspeptic symptoms were associated in 91% of the cases and supraesophageal symptoms in 58%. The symptoms were severe/extremely severe in 56% for heartburn, 35% for regurgitation and 34% for nocturnal heartburn. One in every 6 patients had dysphagia: 14% of them severe/extremely severe. 52% of the patients chose heartburn as the most bothersome symptom, 20% thoracic pain, 8% regurgitation, 6% epigastric pain and 3% nocturnal heartburn. Thus, the most bothersome symptom was a typical one from GERD in 64%, a supraesophageal one in 23% or a dyspeptic one in 10%. Presence of supraesophageal and/or dyspeptic symptoms was associated with worse quality of life (according to SF-12 and QoLRAD). After treatment 93% of the patients had not heartburn and 87% not regurgitation. Response rate was significantly higher (p<0.05) in patients with nocturnal heartburn (96% vs 86%) or regurgitation (95% vs 83%), whereas the association of supraesophageal or dyspeptic symptoms did not influence. Conclusions: The association of supraesophageal and/or dyspeptic symptoms in patients with typical GERD symptoms that were attended in gastroenterology offices is extremely frequent and worsens quality of life. However, therapeutic response PPI treatment is not modified by its coexistence.
M1095 Optical Analysis of Squamous Cells Predicts the Presence of Esophageal Dysplasia and Adenocarcinoma via Partial-Wave Spectroscopic Microscopy Yang Liu, Kevin McGrath, Rajan K. Bista, Julie Holinga, Kevin D. Staton, Kenneth E. Fasanella, Randall Brand Introduction: Common surveillance methodology for Barrett's esophagus (BE) includes fourquadrant, random biopsies every 1-2 cm from the entire length of Barrett's mucosa to identify dysplasia or adenocarcinoma. However, random biopsies are fraught with sampling error, low detection rate for high-grade dysplasia, and unnecessary biopsies. A more practical approach utilizing the concept of a field effect would be to identify patients at risk of developing adenocarcinoma simply by analyzing normal appearing squamous cells from the esophagus. A novel optical technology - partial-wave spectroscopic microscopy (PWS) allows quantitative assessment of subtle structural alterations within single cell and sub-cellular structures with unprecedented sensitivity. We hypothesize that the squamous cells from normal-appearing esophageal epithelium would exhibit subtle structural changes that are detectable by PWS, which would allow the discrimination between those BE patients with adenocarcinoma and dysplasia and those patients without. Methods: A pilot study with 19 patients undergoing scheduled upper endoscopy: 3 controls without BE, 3 with BE with no dysplasia, 2 with BE and low-grade dysplasia (LGD), 5 with BE and high-grade dysplasia (HGD) and 6 BE with adenocarcinoma. We obtained squamous cells from normal appearing esophagus at 20 cm. The cells were fixed with Cytolyt® and subsequently prepared with Thinprep®. PWS analysis was done by observers blinded to clinical/endoscopic data. Patients were categorized into two groups: controls/BE without dysplasia and adenocarcinoma/HGD/ LGD. Results: Several PWS markers (disorder strength, standard deviation of disorder strength, correlation decay, phase, standard deviation of phase) that were statistically significant in discriminating the adenocarcinoma/dysplasia group were identified. A prediction
M1093 Insulin/Insulin Like Growth Factor-1 Pathway in Barrett's Carcinogenesis Katarina B. Greer, Lacie Brenner, Beth Bednarchik, Dawn Dawson, Li Li, Amitabh Chak, Joseph Willis BACKGROUND: Obesity associated carcinogenesis is postulated to be mediated through the proliferative actions of insulin and the insulin like growth factor (IGF) family. The phosphorylation of insulin receptor substrate-1 (pIRS-1) is the first step when insulin and/ or IGF-1 bind to their tyrosine kinase receptors. pIRS1 activates downstream mediators — phosphorylated m-TOR (p-mTOR) and phosphorylated-AKT (p-AKT). The aim of this study was to determine whether the insulin/IGF-1pathway is involved in the sequential progression from Barrett's esophagus (BE) to dysplasia to esophageal adenocarcinoma (EAC). METHODS: Fasting serum levels of insulin, glucose, IGF-1, insulin growth factor binding protein-1
AGA Abstracts
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