- Email: [email protected]
M1423: Predicting Variceal Re-Bleeding; How Real Is the Risk?
Abstracts recommendations made in hypothetical clinical scenarios 60% to 25% of the time with less than 45% of the respondents basing those decisions on perceived guidelines. There is a need for aggressive educational efforts aimed at appropriate endoscopic antibiotic prophylaxis in both primary care and subspecialist populations including gastroenterologists. The design of such an educational intervention is currently underway at Rush.This study has several limitations: It was done at a single center and includes a small sample size and there may also be selection bias due to a non-randomized sample of respondents who chose to participate.
M1422 Gender Preference for Endoscopists in the Adult Hispanic Patient: The Results of a Prospective Study Apurv K. Varia, Ayodele T. Osowo, Hak N. Kim, Gaurav Arora, Victor I. Machicao, Michael B. Fallon, Frank J. Lukens Background: The Hispanic population in the US is increasing which will result in an increase in referrals for endoscopy. Currently, endoscopy is underutilized in this population and colorectal cancer screening rates are lower than Caucasians and African Americans. Gender preference for the endoscopist is recognized as one important factor in compliance with endoscopic procedures. No prospective study has evaluated the gender preferences for the endoscopist in a large sample of Hispanics Aim: To prospectively determine gender preference for endoscopists in the adult Hispanic population and to identify factors that may influence these preferences. Method: Prospective cohort study of 120 consecutive adults Hispanic patients who underwent either outpatient or inpatient endoscopic procedures in a large county hospital system. The patients were asked to complete an anonymous questionnaire prior to their procedure. Data included patient demographics, income level, education level, medical history, social history, abuse history, and gender preferences toward various health-care professionals. Patient with a preference were asked to state a specific reason for their choice. The research personnel administering the questionnaire did not perform the endoscopic procedures. Results: 120 (64 females and 56 males, p⫽NS) consecutive patients were referred for endoscopy. Overall, 35(29%) patients surveyed had a preference for the gender of their endoscopist (35/120; CI: 25-33 %). Of these, 24(69%) patients were female. Overall, women were significantly more likely to have a gender preference vs. men (38 vs. 20%, p ⬍ 0.001). Of the women who had a gender preference, 67% preferred same gender endoscopist. No other demographic or clinical factors were found to influence gender preference for the endoscopist. However, all of our patients had a low yearly income (less than $ 25,000). Of our patients, 11(9%) reported a history of abuse. Of these 3/11 (27%) had a gender preference of their endoscopist. Conclusion: Gender preference for the endoscopist in Hispanics is common. Women were more likely to have a gender preference and both men and women with a preference preferred same gender endoscopist. These findings support that gender preference for the endoscopist maybe an important modifiable factor in compliance with endoscopy in Hispanics.
M1423 Predicting Variceal Re-Bleeding; How Real Is the Risk? Rupesh Nigam, John T. Dugan, David S. Wolf Background: Upper gastrointestinal hemorrhage is the leading cause of death in patients with portal hypertension. Patients with grade three to four esophageal varices, or with both esophageal and gastric varices have higher all cause mortality and morbidity. Over the last several years there have been various new predictive models suggested along with the old validated scores to help predict re-bleeding in variceal bleeders. Our goal was to analyze the actual incidence of re-bleeding in variceal bleeders after the index therapeutic intervention in patients with all cause portal hypertension.Method: IRB approval according to the institutional requirements was obtained. All patients within the age of 18-95, admitted to the medical intensive care unit (MICU) with the diagnosis of gastrointestinal bleeding from September 2007 to September 2009 were analyzed. A retrospective chart review was performed to evaluate the source of bleeding and the cause of bleeding. Subgroup analysis was performed on the patients with upper gastrointestinal bleeding resulting from portal hypertension regardless of cause. Grade or size of the varices was noted and the therapy performed was also documented. Results: Out of the 200 patients admitted to the MICU over a two-year period, 47 cases of portal hypertension resulting in variceal bleeding were identified. All of the variceal bleeders received intravenous proton pump inhibitor (PPI) therapy along with somatostatin analog and intravenous antibiotics upon presentation to the hospital. Upper endoscopy was performed within twenty-four hours of presentation with banding performed in all cases, except one patient where sclerotherapy was performed. Only two patients rebled within five days, with re-bleeding being defined using the Bovena criteria. Subsequently these two patients died during the same hospitalization. Conclusion: Analysis of the outcomes of patients managed as per the recommended guidelines with PPI, somatostatin analog and antibiotic for subacute bacterial peritonitis prevention led to good outcomes in our center with re-bleeding rates not as high as reported in the literature. This leads us to
www.giejournal.org
reconsider the actual need for predictive modeling and the need for more aggressive therapeutic interventions in patients with grade II esophageal or small gastric varices. The average length of stay of any patient with gastrointestinal bleed in our MICU is 4 days. Perhaps by reconsidering the actual incidence of rebleeding in patients with varices the length of stay in the MICU can be reduced, saving valuable resources.
M1424 The Impact of the Quality of Colon Preparation on Surveillance Recommendations Michael C. Larsen, Jonathan P. Terdiman BACKGROUND: Published guidelines for timing of surveillance colonoscopy assume that the entire colon mucosa is visualized and do not provide guidance regarding poor preparations. It is not known how practicing gastroenterologists (GIs) alter the timing of surveillance colonoscopy based on the quality of colon preparation.AIMS: To determine how the quality of preparation during a screening colonoscopy affects the recommendation for the timing of surveillance colonoscopy. METHODS: GIs were shown representative images of four different colonoscopies with differing colon cleanliness. The pictures were designed to represent prep qualities ranging from excellent to poor. For each set of images they were asked to give recommendations as to when a hypothetical patient with no polyps or malignancy on their screening exam should return for a subsequent colonoscopy. Our hospital Institutional Review Board approved this study.RESULTS: 92 GIs completed the survey. Respondents practiced in 14 states and attended 34 GI fellowship programs. 16 of the respondents were current GI fellows. There was considerable variability in GIs’ recommendations, with follow-up timing ranging from 1-2 days to 10 years for identical preparations. Endoscopists generally recommended progressively shorter interval follow-up as colon preparation worsened, with average recommended follow-up of 9.65, 6.36, 2.90 and 1.29 years for the four different preparations. Nearly all respondents recommended 10 year follow-up colonoscopy for the best appearing preparation. For the three imperfect preparations there was a trend towards GIs practicing at academic centers recommending longer interval follow-up vs. GIs in private practice (6.98 vs. 5.92 (p⫽0.10), 3.90 vs. 2.25 (p⫽0.007), and 1.83 vs. 0.98 (p⫽0.06) years). GIs performing more than 20 colonoscopies per week trended towards shorter interval follow-up than those performing fewer than 20 (6.16 vs. 6.62 (p⫽0.47), 2.44 vs. 3.50 (p⫽0.08), and 0.89 vs. 1.83 (p⫽0.04) years). Factors which did not correlate with recommendations include GI’s age, gender, GI fellowship program, fellowship graduation date, perceived quality of preparation in physician’s own practice, personal history of missed large polyp or malignancy and whether the endoscopist is a fellow or an attending.CONCLUSIONS: Gastroenterologists provide disparate recommendations regarding timing of surveillance colonoscopy when colon preparation is not perfect. The characteristics of the gastroenterologist’s practice may impact these recommendations. Further research is needed in order to determine the correct timing of surveillance colonoscopy when colon preparation is not ideal.
M1425 Dramatic Improvement in Colon Preps by Addition of Bisacodyl Tabs Stephen J. Sontag, Thomas G. Schnell, Jack Leya, Harish Bhatia, Janet M. Fidanze, Karen Mclean, Ginger Filkas, Petra Falk, Leniecesa Arceneaux, Erik Delvalle, Sally Melloy INTRODUCTION:Poor C-scope preps result in complications, increased costs, and missed cancers. For the past 8 years of our program, our VA GI lab has been attempting to improve the quality of the C-Scope prep results in veterans. Despite different 1-day and 2-day prep concoctions in 3143 exams, 7% of pts required repeat exam. To determine whether anything could ever improve the 7% failure rate, we attempted something bold: We added 12 tabs (60mg) of bisacodyl to our standard prep.PURPOSE:With the rationale that “once you take the pills, there is no going back”, we set out to determine whether the new prep would reduce the need for repeat exams. METHODS:3806 consecutive pts were prepped by the Nurse Prep clinic in the same manner as the previous 3143 pts, except for the bisacodyl. Pts were instructed as follows: Day before exam: (1) begin clear liquid diet, (2) take all 12 (5mg) bisacodyl tablets (60mg total), (3) drink the gallon of Co-lyte in the early afternoon, (4) drink 10oz bottle of Mag Citrate in the late afternoon, and (5) continue liquids for the rest of the day. Pts reported to the lab on the day after the prep. A 5-point scale with strict definitions was used to grade quality of preps.RESULTS:There was an immediate improvement in outcomes: A 12% increase in “Good/Excellent” preps (95% CI⫽10-14, P⬍0.0001) and a 3% decrease in “Poor” preps. Age was unrelated to the quality of the prep (P⫽NS) for all preps. Thus, for every 1000 C-Scopes, 120 that would have required time-delaying irrigation actually required none, and 30 C-Scopes that would have required repeat were completed successfully.CONCLUSION:Ingestion of 12 bisacodyl tablets (60mg) before beginning the standard Co-lyte/Mag Citrate prep on the morning prior to the C-
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB217
M1422 Gender Preference for Endoscopists in the Adult Hispanic Patient: The Results of a Prospective Study Apurv K. Varia, Ayodele T. Osowo, Hak N. Kim, Gaurav Arora, Victor I. Machicao, Michael B. Fallon, Frank J. Lukens Background: The Hispanic population in the US is increasing which will result in an increase in referrals for endoscopy. Currently, endoscopy is underutilized in this population and colorectal cancer screening rates are lower than Caucasians and African Americans. Gender preference for the endoscopist is recognized as one important factor in compliance with endoscopic procedures. No prospective study has evaluated the gender preferences for the endoscopist in a large sample of Hispanics Aim: To prospectively determine gender preference for endoscopists in the adult Hispanic population and to identify factors that may influence these preferences. Method: Prospective cohort study of 120 consecutive adults Hispanic patients who underwent either outpatient or inpatient endoscopic procedures in a large county hospital system. The patients were asked to complete an anonymous questionnaire prior to their procedure. Data included patient demographics, income level, education level, medical history, social history, abuse history, and gender preferences toward various health-care professionals. Patient with a preference were asked to state a specific reason for their choice. The research personnel administering the questionnaire did not perform the endoscopic procedures. Results: 120 (64 females and 56 males, p⫽NS) consecutive patients were referred for endoscopy. Overall, 35(29%) patients surveyed had a preference for the gender of their endoscopist (35/120; CI: 25-33 %). Of these, 24(69%) patients were female. Overall, women were significantly more likely to have a gender preference vs. men (38 vs. 20%, p ⬍ 0.001). Of the women who had a gender preference, 67% preferred same gender endoscopist. No other demographic or clinical factors were found to influence gender preference for the endoscopist. However, all of our patients had a low yearly income (less than $ 25,000). Of our patients, 11(9%) reported a history of abuse. Of these 3/11 (27%) had a gender preference of their endoscopist. Conclusion: Gender preference for the endoscopist in Hispanics is common. Women were more likely to have a gender preference and both men and women with a preference preferred same gender endoscopist. These findings support that gender preference for the endoscopist maybe an important modifiable factor in compliance with endoscopy in Hispanics.
M1423 Predicting Variceal Re-Bleeding; How Real Is the Risk? Rupesh Nigam, John T. Dugan, David S. Wolf Background: Upper gastrointestinal hemorrhage is the leading cause of death in patients with portal hypertension. Patients with grade three to four esophageal varices, or with both esophageal and gastric varices have higher all cause mortality and morbidity. Over the last several years there have been various new predictive models suggested along with the old validated scores to help predict re-bleeding in variceal bleeders. Our goal was to analyze the actual incidence of re-bleeding in variceal bleeders after the index therapeutic intervention in patients with all cause portal hypertension.Method: IRB approval according to the institutional requirements was obtained. All patients within the age of 18-95, admitted to the medical intensive care unit (MICU) with the diagnosis of gastrointestinal bleeding from September 2007 to September 2009 were analyzed. A retrospective chart review was performed to evaluate the source of bleeding and the cause of bleeding. Subgroup analysis was performed on the patients with upper gastrointestinal bleeding resulting from portal hypertension regardless of cause. Grade or size of the varices was noted and the therapy performed was also documented. Results: Out of the 200 patients admitted to the MICU over a two-year period, 47 cases of portal hypertension resulting in variceal bleeding were identified. All of the variceal bleeders received intravenous proton pump inhibitor (PPI) therapy along with somatostatin analog and intravenous antibiotics upon presentation to the hospital. Upper endoscopy was performed within twenty-four hours of presentation with banding performed in all cases, except one patient where sclerotherapy was performed. Only two patients rebled within five days, with re-bleeding being defined using the Bovena criteria. Subsequently these two patients died during the same hospitalization. Conclusion: Analysis of the outcomes of patients managed as per the recommended guidelines with PPI, somatostatin analog and antibiotic for subacute bacterial peritonitis prevention led to good outcomes in our center with re-bleeding rates not as high as reported in the literature. This leads us to
www.giejournal.org
reconsider the actual need for predictive modeling and the need for more aggressive therapeutic interventions in patients with grade II esophageal or small gastric varices. The average length of stay of any patient with gastrointestinal bleed in our MICU is 4 days. Perhaps by reconsidering the actual incidence of rebleeding in patients with varices the length of stay in the MICU can be reduced, saving valuable resources.
M1424 The Impact of the Quality of Colon Preparation on Surveillance Recommendations Michael C. Larsen, Jonathan P. Terdiman BACKGROUND: Published guidelines for timing of surveillance colonoscopy assume that the entire colon mucosa is visualized and do not provide guidance regarding poor preparations. It is not known how practicing gastroenterologists (GIs) alter the timing of surveillance colonoscopy based on the quality of colon preparation.AIMS: To determine how the quality of preparation during a screening colonoscopy affects the recommendation for the timing of surveillance colonoscopy. METHODS: GIs were shown representative images of four different colonoscopies with differing colon cleanliness. The pictures were designed to represent prep qualities ranging from excellent to poor. For each set of images they were asked to give recommendations as to when a hypothetical patient with no polyps or malignancy on their screening exam should return for a subsequent colonoscopy. Our hospital Institutional Review Board approved this study.RESULTS: 92 GIs completed the survey. Respondents practiced in 14 states and attended 34 GI fellowship programs. 16 of the respondents were current GI fellows. There was considerable variability in GIs’ recommendations, with follow-up timing ranging from 1-2 days to 10 years for identical preparations. Endoscopists generally recommended progressively shorter interval follow-up as colon preparation worsened, with average recommended follow-up of 9.65, 6.36, 2.90 and 1.29 years for the four different preparations. Nearly all respondents recommended 10 year follow-up colonoscopy for the best appearing preparation. For the three imperfect preparations there was a trend towards GIs practicing at academic centers recommending longer interval follow-up vs. GIs in private practice (6.98 vs. 5.92 (p⫽0.10), 3.90 vs. 2.25 (p⫽0.007), and 1.83 vs. 0.98 (p⫽0.06) years). GIs performing more than 20 colonoscopies per week trended towards shorter interval follow-up than those performing fewer than 20 (6.16 vs. 6.62 (p⫽0.47), 2.44 vs. 3.50 (p⫽0.08), and 0.89 vs. 1.83 (p⫽0.04) years). Factors which did not correlate with recommendations include GI’s age, gender, GI fellowship program, fellowship graduation date, perceived quality of preparation in physician’s own practice, personal history of missed large polyp or malignancy and whether the endoscopist is a fellow or an attending.CONCLUSIONS: Gastroenterologists provide disparate recommendations regarding timing of surveillance colonoscopy when colon preparation is not perfect. The characteristics of the gastroenterologist’s practice may impact these recommendations. Further research is needed in order to determine the correct timing of surveillance colonoscopy when colon preparation is not ideal.
M1425 Dramatic Improvement in Colon Preps by Addition of Bisacodyl Tabs Stephen J. Sontag, Thomas G. Schnell, Jack Leya, Harish Bhatia, Janet M. Fidanze, Karen Mclean, Ginger Filkas, Petra Falk, Leniecesa Arceneaux, Erik Delvalle, Sally Melloy INTRODUCTION:Poor C-scope preps result in complications, increased costs, and missed cancers. For the past 8 years of our program, our VA GI lab has been attempting to improve the quality of the C-Scope prep results in veterans. Despite different 1-day and 2-day prep concoctions in 3143 exams, 7% of pts required repeat exam. To determine whether anything could ever improve the 7% failure rate, we attempted something bold: We added 12 tabs (60mg) of bisacodyl to our standard prep.PURPOSE:With the rationale that “once you take the pills, there is no going back”, we set out to determine whether the new prep would reduce the need for repeat exams. METHODS:3806 consecutive pts were prepped by the Nurse Prep clinic in the same manner as the previous 3143 pts, except for the bisacodyl. Pts were instructed as follows: Day before exam: (1) begin clear liquid diet, (2) take all 12 (5mg) bisacodyl tablets (60mg total), (3) drink the gallon of Co-lyte in the early afternoon, (4) drink 10oz bottle of Mag Citrate in the late afternoon, and (5) continue liquids for the rest of the day. Pts reported to the lab on the day after the prep. A 5-point scale with strict definitions was used to grade quality of preps.RESULTS:There was an immediate improvement in outcomes: A 12% increase in “Good/Excellent” preps (95% CI⫽10-14, P⬍0.0001) and a 3% decrease in “Poor” preps. Age was unrelated to the quality of the prep (P⫽NS) for all preps. Thus, for every 1000 C-Scopes, 120 that would have required time-delaying irrigation actually required none, and 30 C-Scopes that would have required repeat were completed successfully.CONCLUSION:Ingestion of 12 bisacodyl tablets (60mg) before beginning the standard Co-lyte/Mag Citrate prep on the morning prior to the C-
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB217