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M1544: UK National Bowel Cancer Screening Programme: A Tertiary Centre Experience
Abstracts little published data on whether these patients maintain cardiopulmonary stability during endoscopy. We hypothesized that endoscopy can be safely done in patients with LVADs without cardiopulmonary deterioration.METHODS: A list of patients with LVAD implantation from 2007 to 2009 was obtained. Patients who underwent endoscopy were then identified within this group. A retrospective chart review identified type of LVAD, indication for procedure, antithrombotic agents, and procedural and post-procedural complications. RESULTS: From 4/2007 to 7/2009, 41 LVADs (30 men, 11 women) were implanted, including 18 pulsatile flow and 23 continuous flow. 12/41 patients (29%) underwent either upper (12) or lower endoscopy (13) for a total of 25 procedures. The mean age was 60.4 years. Of the 12 patients, 9 had continuous and 4 had pulsatile flow devices (1 patient had 2 devices). Indications for endoscopy included GI bleed (12), anemia (7), pre-transplant evaluation for colorectal cancer (3), follow-up for history of GIB (2), and nausea/vomiting (1). 21 procedures were done using MAC anesthesia, 3 with fentanyl drips (in sedated/intubated pts), and 1 without any sedation. Of the 25 procedures, there were no significant cardiopulmonary complications. All patients receiving MAC were on standard oxygen via nasal cannula throughout the procedure. However, 6/25 (24%) required boluses of intravenous phenylephrine to maintain adequate flow volume. In these 6 cases, a different anesthesiologist monitored each patient. The post-procedure course was complication-free in 22/25 (88%) procedures. The remaining 3 were complicated by upper GIB (secondary to angioectasia and gastric ulcer) and hematochezia (secondary to postpolypectomy bleed) up to 10 days post-procedure. All of these patients had continuous flow LVADs requiring chronic anticoagulation. They were treated with standard coagulation techniques and remained complication-free. CONCLUSION: The patients studied underwent endoscopy without significant cardiopulmonary compromise. Our results show that endoscopy can be safely done in this population. GI bleeding was the most common indication for endoscopy in this cohort, and an increased rate of post-procedural bleeding was observed. Prior reports of increased GI bleeding have been reported in this group of patients, which has been confirmed by our data.
M1543 Endoscopic Findings Thought to Be a Source of Blood Loss in Patients With Iron Deficiency Anemia Do Not Correlate With Stool Blood Natalie M. Bachir, Don C. Rockey Background: Iron deficiency anemia (IDA) is a common indication for referral for endoscopy in adults and bidirectional endoscopy is currently considered to be standard of care. However, assigning specific gastrointestinal (GI) tract lesions to clinically meaningful blood loss (i.e. that appropriately explain IDA) is not evidence-based. Aim: To prospectively correlate lesions found on endoscopy with quantification of stool blood in patients undergoing evaluation of unexplained IDA. Methods: Adult outpatients presenting to the GI unit for evaluation of IDA undergoing bidirectional endoscopy were prospectively enrolled. Extensive clinical and laboratory data were collected including celiac disease and iron status, socioepidemiologic information, and medical and surgical history. Subjects with IDA were compared to a control group of patients without iron deficiency or anemia. Endoscopists were blinded. Bleeding lesions were carefully defined using the standard classification system (carcinoma, adenomatous polyps ⬎1.5 cm, vascular ectasias numbering ⱖ5 or size ⱖ8 mm, active colitis, ulcer ⬎1 cm; esophageal erosions ⱖ5% of mucosal surface, gastritis numbering ⱖ50 erosions of ⱖ1 mm w/white bases encircled by erythema). Fecal blood was detected using both a qualitative guaiac-based method (Hemoccult) and a quantitative measure of heme-derived porphyrins (Hemoquant). For each of these tests, 3 samples were taken on different days. Results: 44 subjects were enrolled; 30 subjects had IDA, and 14 subjects served as controls. No patient had celiac disease. Age, gender, BMI, race, and ethnicity were all similar between the two groups (p ⫽ NS). Five (17%) subjects with IDA and 2 (14%) control subjects had lesions identified on endoscopy felt to be consistent with chronic occult GI bleeding. 24 subjects returned stool for analysis. At least one Hemoccult test was positive in 14 subjects overall; 9 (30%) subjects with IDA, and 5 (36%) control subjects. Hemoquant was suggestive of significant blood loss (⬎2 mg hemoglobin/g feces) in 6 subjects (20%) with IDA, and in 1 (7%) control subject. Using Hemoquant as the gold standard, endoscopic evaluation achieved a sensitivity of 33% and a specificity of 88% in the subjects with IDA. Conclusion: Endoscopic assessment of putative bleeding lesions in patients with IDA correlates poorly with fecal blood. Our data indicate that better methods of assigning blood loss to specific GI tract abnormalities are required. It is possible that hemoquant testing should be part of the algorithm in evaluation of patients with IDA, to help guide evaluation of the GI tract. Support: This study was supported by NIH Grant Number UL1RR024982.
AB250 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
M1544 UK National Bowel Cancer Screening Programme: A Tertiary Centre Experience Sachin Gupta, Chris H. Fraser, Noriko Suzuki, Maggie Vance, Brian P. Saunders, Siwan Thomas-Gibson Introduction:The Wolfson Unit for Endoscopy, St. Mark’s Hospital, UK is recognised as a world centre for excellence by the World Organisation of Digestive Endoscopy (OMED). The St. Mark’s Bowel Cancer Screening Centre (BCSC) was one of the first English screening centres rolled out in 2006. The programme screens patients between 60-75 faecal occult blood tests (FOBT) and those with a positive result are offered a colonoscopy. We report the preliminary experience of St Mark’s BCSC over the first 35 months of screening.Aims and Methods:To review the outcomes of 1488 screening participants referred following positive FOBT. Those unfit for colonoscopy were offered alternatives such as CT Virtual Colonoscopy (VC). Data regarding gender, age, colonoscopy findings and screening outcomes were analysed. Polyps were risk stratified according to the British Society of Gastroenterology polyp surveillance guidelines.Results:98815 FOBT kits were sent out and 42523 returned (43 % uptake).1488 positive FOBT participants were referred to the nurse clinic at St. Mark’s. 1339 (90%) attended. 57% were men. 1138 (85%) were suitable for colonoscopy, 122 (9%) for VC and 17 (1%) for flexible sigmoidoscopy. 62 (5%) were not referred further on medical grounds. 1057 (79%) screenees underwent first procedure colonoscopy, 115 had a VC and 8 had a flexible sigmoidoscopy. 514 (44%) procedures were ‘normal’, 583 (50%) patients had polyps (155 (26%) high risk , 170 (29%) intermediate risk and 258 (45%) low risk polyps). 583 patients had 1625 polyps (average 2.8 polyps per patient). 96% were adenomas. Median polyp size was 5mm (1-80). 74 patients (6%) had colorectal cancer. 3 patients had non-colonic incidental cancers. Overall, 1200 colonoscopies were performed by five screeners till September 2009 (1057 first procedure colonoscopies, 82 repeat colonoscopies, 61 surveillance procedures), with a 96% completion rate. There were 8 post polypectomy bleeds (only 1 requiring transfusion) and 3 minor complications. There was 1 post polypectomy syndrome and 1 perforation (both managed conservatively). Conclusion:Over the period reviewed, more than 1200 colonoscopies were performed with excellent (96%) completion rates. Significant pathology (cancers and polyps) was found in 45% of patients with a positive FOBT. Despite the polyp/adenoma detection rates being higher than those expected, cancer rates were lower than national figures. This was possibly due to a previous flexible sigmoidoscopy trial in the centre in 1999, which picked up a number of early left sided colonic cancers.
M1545 Non Surgical Management of Dysphagia in Oculopharyngeal Muscular Dysptrophy (OPMD), New Mexico (NM) Experience Mohamed O. Othman, Michael D. Gilles, Lance T. Taylor, Amro Elfeki, Leslie Morrison, Martin G. Kistin, Thomas Y. Ma OPMD is a rare (1 in 100,000) hereditary myopathy characterized by progressive ptosis, dysphagia and muscle weakness. NM has the largest cohort of OPMD patients in the US. Majority of OPMD patients develop progressive dysphagia, and cricopharyngeal myotomy had been the main therapeutic modality. Nonsurgical approaches including botulinum toxin intramuscular injections (BOTOX) and Upper Esophageal Sphincter (UES) dilation have been reported to be effective in case reports and small clinical series. There have not been any comparative studies assessing the success of non-surgical approaches. A retrospective study was undertaken to compare the efficacy of non-surgical approaches. Methods: Retrospective chart review of patients diagnosed with OPMD in our institution between 1999 and 2009. Demographic data, treatment modalities for dysphagia and treatment response were collected. Descriptive statistics and Frequency statistics were used for continuous and categorical data respectively. Fisher exact test was used to compare treatment response. Logistic regression analysis was done to evaluate factors affecting treatment response. Results: 100 patients (65 F and 35 M) met the inclusion criteria. Mean age at diagnosis was 59 yrs. 79% of the patients were Hispanic. 94% of the patients had a positive family history. 78% of the patients had dysphagia with mean age of onset at 55 yrs. Dysphagia was progressive in 83% of patients, and 21% had significant weight loss. 45% of the patients had heartburn. Swallow evaluation was done in 62 patients. Pooling was the most common finding (60%) followed by Crichopharyngeal bar (29%) and aspiration (24%). Dysphagia was managed with UES dilation (Savary) in 20 patients, BOTOX in 12 patients and both procedures in 8 patients. Improvement of dysphagia occurred in 66% of patients with BOTOX injections and 82% with esophageal dilation (P⫽ 0.4). 5 patients in the BOTOX group had minor complications (dysphonia, hoarseness of voice and soreness) while 2 patients in the dilation group had minor complications (dyspnea and epigastric discomfort) (P⫽0.09). The treatment response was not different by gender (P⫽ 0.3). Hispanic patients had higher treatment response compared to non-Hispanic patients (P⫽ 0.01). Conclusion: Dysphagia is the most serious complication in OPMD and can lead to aspiration. This is the largest published study comparing the efficacy of non-surgical approaches in managing dysphagia in OPMD. BOTOX injection and UES dilation were equally effective and represent an alternative approach to myotomy. A large randomized study is
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M1543 Endoscopic Findings Thought to Be a Source of Blood Loss in Patients With Iron Deficiency Anemia Do Not Correlate With Stool Blood Natalie M. Bachir, Don C. Rockey Background: Iron deficiency anemia (IDA) is a common indication for referral for endoscopy in adults and bidirectional endoscopy is currently considered to be standard of care. However, assigning specific gastrointestinal (GI) tract lesions to clinically meaningful blood loss (i.e. that appropriately explain IDA) is not evidence-based. Aim: To prospectively correlate lesions found on endoscopy with quantification of stool blood in patients undergoing evaluation of unexplained IDA. Methods: Adult outpatients presenting to the GI unit for evaluation of IDA undergoing bidirectional endoscopy were prospectively enrolled. Extensive clinical and laboratory data were collected including celiac disease and iron status, socioepidemiologic information, and medical and surgical history. Subjects with IDA were compared to a control group of patients without iron deficiency or anemia. Endoscopists were blinded. Bleeding lesions were carefully defined using the standard classification system (carcinoma, adenomatous polyps ⬎1.5 cm, vascular ectasias numbering ⱖ5 or size ⱖ8 mm, active colitis, ulcer ⬎1 cm; esophageal erosions ⱖ5% of mucosal surface, gastritis numbering ⱖ50 erosions of ⱖ1 mm w/white bases encircled by erythema). Fecal blood was detected using both a qualitative guaiac-based method (Hemoccult) and a quantitative measure of heme-derived porphyrins (Hemoquant). For each of these tests, 3 samples were taken on different days. Results: 44 subjects were enrolled; 30 subjects had IDA, and 14 subjects served as controls. No patient had celiac disease. Age, gender, BMI, race, and ethnicity were all similar between the two groups (p ⫽ NS). Five (17%) subjects with IDA and 2 (14%) control subjects had lesions identified on endoscopy felt to be consistent with chronic occult GI bleeding. 24 subjects returned stool for analysis. At least one Hemoccult test was positive in 14 subjects overall; 9 (30%) subjects with IDA, and 5 (36%) control subjects. Hemoquant was suggestive of significant blood loss (⬎2 mg hemoglobin/g feces) in 6 subjects (20%) with IDA, and in 1 (7%) control subject. Using Hemoquant as the gold standard, endoscopic evaluation achieved a sensitivity of 33% and a specificity of 88% in the subjects with IDA. Conclusion: Endoscopic assessment of putative bleeding lesions in patients with IDA correlates poorly with fecal blood. Our data indicate that better methods of assigning blood loss to specific GI tract abnormalities are required. It is possible that hemoquant testing should be part of the algorithm in evaluation of patients with IDA, to help guide evaluation of the GI tract. Support: This study was supported by NIH Grant Number UL1RR024982.
AB250 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
M1544 UK National Bowel Cancer Screening Programme: A Tertiary Centre Experience Sachin Gupta, Chris H. Fraser, Noriko Suzuki, Maggie Vance, Brian P. Saunders, Siwan Thomas-Gibson Introduction:The Wolfson Unit for Endoscopy, St. Mark’s Hospital, UK is recognised as a world centre for excellence by the World Organisation of Digestive Endoscopy (OMED). The St. Mark’s Bowel Cancer Screening Centre (BCSC) was one of the first English screening centres rolled out in 2006. The programme screens patients between 60-75 faecal occult blood tests (FOBT) and those with a positive result are offered a colonoscopy. We report the preliminary experience of St Mark’s BCSC over the first 35 months of screening.Aims and Methods:To review the outcomes of 1488 screening participants referred following positive FOBT. Those unfit for colonoscopy were offered alternatives such as CT Virtual Colonoscopy (VC). Data regarding gender, age, colonoscopy findings and screening outcomes were analysed. Polyps were risk stratified according to the British Society of Gastroenterology polyp surveillance guidelines.Results:98815 FOBT kits were sent out and 42523 returned (43 % uptake).1488 positive FOBT participants were referred to the nurse clinic at St. Mark’s. 1339 (90%) attended. 57% were men. 1138 (85%) were suitable for colonoscopy, 122 (9%) for VC and 17 (1%) for flexible sigmoidoscopy. 62 (5%) were not referred further on medical grounds. 1057 (79%) screenees underwent first procedure colonoscopy, 115 had a VC and 8 had a flexible sigmoidoscopy. 514 (44%) procedures were ‘normal’, 583 (50%) patients had polyps (155 (26%) high risk , 170 (29%) intermediate risk and 258 (45%) low risk polyps). 583 patients had 1625 polyps (average 2.8 polyps per patient). 96% were adenomas. Median polyp size was 5mm (1-80). 74 patients (6%) had colorectal cancer. 3 patients had non-colonic incidental cancers. Overall, 1200 colonoscopies were performed by five screeners till September 2009 (1057 first procedure colonoscopies, 82 repeat colonoscopies, 61 surveillance procedures), with a 96% completion rate. There were 8 post polypectomy bleeds (only 1 requiring transfusion) and 3 minor complications. There was 1 post polypectomy syndrome and 1 perforation (both managed conservatively). Conclusion:Over the period reviewed, more than 1200 colonoscopies were performed with excellent (96%) completion rates. Significant pathology (cancers and polyps) was found in 45% of patients with a positive FOBT. Despite the polyp/adenoma detection rates being higher than those expected, cancer rates were lower than national figures. This was possibly due to a previous flexible sigmoidoscopy trial in the centre in 1999, which picked up a number of early left sided colonic cancers.
M1545 Non Surgical Management of Dysphagia in Oculopharyngeal Muscular Dysptrophy (OPMD), New Mexico (NM) Experience Mohamed O. Othman, Michael D. Gilles, Lance T. Taylor, Amro Elfeki, Leslie Morrison, Martin G. Kistin, Thomas Y. Ma OPMD is a rare (1 in 100,000) hereditary myopathy characterized by progressive ptosis, dysphagia and muscle weakness. NM has the largest cohort of OPMD patients in the US. Majority of OPMD patients develop progressive dysphagia, and cricopharyngeal myotomy had been the main therapeutic modality. Nonsurgical approaches including botulinum toxin intramuscular injections (BOTOX) and Upper Esophageal Sphincter (UES) dilation have been reported to be effective in case reports and small clinical series. There have not been any comparative studies assessing the success of non-surgical approaches. A retrospective study was undertaken to compare the efficacy of non-surgical approaches. Methods: Retrospective chart review of patients diagnosed with OPMD in our institution between 1999 and 2009. Demographic data, treatment modalities for dysphagia and treatment response were collected. Descriptive statistics and Frequency statistics were used for continuous and categorical data respectively. Fisher exact test was used to compare treatment response. Logistic regression analysis was done to evaluate factors affecting treatment response. Results: 100 patients (65 F and 35 M) met the inclusion criteria. Mean age at diagnosis was 59 yrs. 79% of the patients were Hispanic. 94% of the patients had a positive family history. 78% of the patients had dysphagia with mean age of onset at 55 yrs. Dysphagia was progressive in 83% of patients, and 21% had significant weight loss. 45% of the patients had heartburn. Swallow evaluation was done in 62 patients. Pooling was the most common finding (60%) followed by Crichopharyngeal bar (29%) and aspiration (24%). Dysphagia was managed with UES dilation (Savary) in 20 patients, BOTOX in 12 patients and both procedures in 8 patients. Improvement of dysphagia occurred in 66% of patients with BOTOX injections and 82% with esophageal dilation (P⫽ 0.4). 5 patients in the BOTOX group had minor complications (dysphonia, hoarseness of voice and soreness) while 2 patients in the dilation group had minor complications (dyspnea and epigastric discomfort) (P⫽0.09). The treatment response was not different by gender (P⫽ 0.3). Hispanic patients had higher treatment response compared to non-Hispanic patients (P⫽ 0.01). Conclusion: Dysphagia is the most serious complication in OPMD and can lead to aspiration. This is the largest published study comparing the efficacy of non-surgical approaches in managing dysphagia in OPMD. BOTOX injection and UES dilation were equally effective and represent an alternative approach to myotomy. A large randomized study is
www.giejournal.org