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Mo1085 Persistent Pain After Colonic Endoscopic Mucosal Resection: Predictors, a Management Algorithm and Outcomes
Abstracts
Clip (n[24) Modality (in addition to clips) (n) Clips only Clips + Epi Clips + APC Clips+APC+Epi Clips + bipolar Immediate control of bleeding (n) Immediate complications (n) Length of stay (mean, range) Rebleeding or persistence of anemia (n) Yes No No follow up Time to rebleeding (days mean, range) Follow up (days mean, range) Lost to follow up (n)
ratio of 3.5 (95% confidence interval 1.4-8.6, pZ .006) (Table 1). Conclusion: Pain after EMR occurs in 20-25 % of patients and is associated with larger lesion size in a multivariate analysis. If pain subsides after parenteral acetaminophen and does not recur the patient can be safely and confidently discharged to the step down recovery area and after medical review allowed to leave hospital. PP despite parenteral acetaminophen heralds a more serious scenario and imaging should be considered when stronger analgesics do not relieve the pain.
APC (n[30) NA
7 6 8 1 2 24 1 13 (2-71)
30 0 4.4 (2-7)
9 10 5 218 (1-684) 229 (7-717) 3
11 13 6 388 (8-1630) 547 (11-1625) 6
NS NS NS NS
NS
NS: non significant; NA: not applicable.
Image 1: (A) actively bleeding cecal AVM. (B) control of bleeding with 2 hemostatic clips.
Mo1085 Persistent Pain After Colonic Endoscopic Mucosal Resection: Predictors, a Management Algorithm and Outcomes Lobke Desomer*1, David J. Tate1, Halim Awadie1, Leshni Pillay1, Golo Ahlenstiel1, Michael J. Bourke1,2 1 Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; 2Sydney University, Sydney, New South Wales, Australia Introduction: Endoscopic mucosal resection (EMR) of large (20 mm) laterally spreading colonic lesions (LSL) is safe, effective and superior to surgery. The advantage is based on a day stay model of care however the most common adverse event is abdominal pain and this is a major impediment to its efficiency. No prospective data exist on the optimal selection of analgesics, necessary recovery period or triggers that should alert the practitioner to a more serious trajectory and the need for escalation of care. Methods: Consecutive patients with LSL referred for EMR at a single, tertiary referral centre were included. Patient and lesion characteristics and peri-procedural data were prospectively collected. Standard post EMR care included 2 hours in 1st stage recovery followed by 1 hour in 2nd stage where clear fluids were given and patients discharged if well. Persistent post-procedural pain (PP) was graded from 0 to 10 using a Visual Analogue Scale (VAS). If PP occurred >5 minutes, 1 gram of acetaminophen IV was administered and outcomes were monitored. If pain settled the patient was transferred to second stage recovery after medical review. PP >30 minutes lead to clinical review and upgrade of analgesics to fentanyl, with a starting dose of 25 micrograms (mcg) up to a maximum of 100 mcg. Investigations, admission and interventions for PP were recorded. Results: 133 patients (51.1% male, mean age 69.9 years, standard deviation 10.5) with 133 lesions (median size 35mm, interquartile range (IQR) 30-48.8, 57.9% hepatic flexure and proximal) were included between February and November 2016. 31/133 (23.2%) of patients had PP requiring intervention (median VAS 5, IQR 2.75-5.25). 25/31 (80.6%) had resolution of pain with acetaminophen and were ultimately discharged without sequelae. 6/31 patients (19.4%) required fentanyl, with 100 mcg in 2 patients. A CT scan was performed in these 2 patients, showing serositis in 1 and no abnormalities in the other. Predictors of PP were lesion size (35 mm, IQR 25-40, in the group without pain versus 40 mm, IQR 30-50, pZ.024), Paris 0-IIa+Is (29.4% in the group without pain versus 48.4%, pZ.01) and intra-procedural bleeding requiring endoscopic control (51% in the group without pain versus 73.3%, pZ.032). Lesion size 45mm was the only independent variable on multivariate analysis with an odds
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Mo1086 Severity of Gastrointestinal Bleeding in Patients Treated With Direct-Acting Oral Anticoagulants (DOACS) Mark M. Brodie*, Tyler Smith, Jill Newman, Don C. Rockey Medical University of South Carolina, Charleston, SC Background: Direct-acting oral anticoagulants (DOACs), which have recently been approved for stroke prevention in non-valvular atrial fibrillation and treatment of venous thromboembolism, have become increasingly preferred over warfarin given their predictable pharmacodynamics and lack of required monitoring. DOACs have been shown to be associated with an increased frequency of gastrointestinal bleeding (GIB) compared to warfarin, but the severity of GIB in these patients is poorly understood. Methods: We retrospectively evaluated medical records of patients with diagnosis codes of GIB (nZ8,496) from 2010-2016. We identified 61 patients with GIB episodes while treated with DOACs (rivaroxaban, dabigatran, or apixaban) and 119 patients with GIB while on warfarin. We randomly selected a control group of 242 patients with GIB on no anticoagulation from the same data set. Outcomes included hospitalizations, blood transfusions, GIB requiring either endoscopic or surgical intervention, and 30-day mortality. Results: The DOAC, warfarin, and control groups were similar in terms of age and underlying comorbidity (Charlson Comorbidity Index). The DOAC group had more concomitant aspirin use than the warfarin group (Table 1). GIB was classified as upper (nZ166), lower (nZ69), anorectal (nZ168), and other (nZ19). The DOAC group had a trend toward fewer hospitalizations (51% vs 64%, pZ0.07) and required transfusions less frequently (28% vs 42%, pZ0.04) compared with the warfarin group (Table 2). The DOAC and control groups were similar with regard to hospitalizations and blood transfusions. There were no significant differences between any groups in 30-day mortality or need for intervention. Conclusion: Although prior studies have shown a higher frequency of GIB in patients treated with DOACs compared to warfarin, our data suggest that the severity of GIB in patients taking DOACs may be less, with fewer transfusions and a trend toward fewer hospitalizations. This was despite significantly greater concomitant aspirin use in the DOAC group.
Table 1 Demographic and Clinical Features
Control (n[242)
DOAC (n[61)
Warfarin (n[119)
Age (Years, Mean +/- SD) Female Caucasian African American Other Race Charlson Comorbidity Index (Mean +/- SD) Concomitant Aspirin Use
63 +/- 13 46% 46% 52% 1.7% 4.0 +/- 2.5 47%
68 +/- 13 38% 79% 21% 0% 4.5 +/- 2.0 43%
66 +/- 14 59% 52% 46% 2.5% 4.4 +/- 2.1 14%
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB421
Clip (n[24) Modality (in addition to clips) (n) Clips only Clips + Epi Clips + APC Clips+APC+Epi Clips + bipolar Immediate control of bleeding (n) Immediate complications (n) Length of stay (mean, range) Rebleeding or persistence of anemia (n) Yes No No follow up Time to rebleeding (days mean, range) Follow up (days mean, range) Lost to follow up (n)
ratio of 3.5 (95% confidence interval 1.4-8.6, pZ .006) (Table 1). Conclusion: Pain after EMR occurs in 20-25 % of patients and is associated with larger lesion size in a multivariate analysis. If pain subsides after parenteral acetaminophen and does not recur the patient can be safely and confidently discharged to the step down recovery area and after medical review allowed to leave hospital. PP despite parenteral acetaminophen heralds a more serious scenario and imaging should be considered when stronger analgesics do not relieve the pain.
APC (n[30) NA
7 6 8 1 2 24 1 13 (2-71)
30 0 4.4 (2-7)
9 10 5 218 (1-684) 229 (7-717) 3
11 13 6 388 (8-1630) 547 (11-1625) 6
NS NS NS NS
NS
NS: non significant; NA: not applicable.
Image 1: (A) actively bleeding cecal AVM. (B) control of bleeding with 2 hemostatic clips.
Mo1085 Persistent Pain After Colonic Endoscopic Mucosal Resection: Predictors, a Management Algorithm and Outcomes Lobke Desomer*1, David J. Tate1, Halim Awadie1, Leshni Pillay1, Golo Ahlenstiel1, Michael J. Bourke1,2 1 Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; 2Sydney University, Sydney, New South Wales, Australia Introduction: Endoscopic mucosal resection (EMR) of large (20 mm) laterally spreading colonic lesions (LSL) is safe, effective and superior to surgery. The advantage is based on a day stay model of care however the most common adverse event is abdominal pain and this is a major impediment to its efficiency. No prospective data exist on the optimal selection of analgesics, necessary recovery period or triggers that should alert the practitioner to a more serious trajectory and the need for escalation of care. Methods: Consecutive patients with LSL referred for EMR at a single, tertiary referral centre were included. Patient and lesion characteristics and peri-procedural data were prospectively collected. Standard post EMR care included 2 hours in 1st stage recovery followed by 1 hour in 2nd stage where clear fluids were given and patients discharged if well. Persistent post-procedural pain (PP) was graded from 0 to 10 using a Visual Analogue Scale (VAS). If PP occurred >5 minutes, 1 gram of acetaminophen IV was administered and outcomes were monitored. If pain settled the patient was transferred to second stage recovery after medical review. PP >30 minutes lead to clinical review and upgrade of analgesics to fentanyl, with a starting dose of 25 micrograms (mcg) up to a maximum of 100 mcg. Investigations, admission and interventions for PP were recorded. Results: 133 patients (51.1% male, mean age 69.9 years, standard deviation 10.5) with 133 lesions (median size 35mm, interquartile range (IQR) 30-48.8, 57.9% hepatic flexure and proximal) were included between February and November 2016. 31/133 (23.2%) of patients had PP requiring intervention (median VAS 5, IQR 2.75-5.25). 25/31 (80.6%) had resolution of pain with acetaminophen and were ultimately discharged without sequelae. 6/31 patients (19.4%) required fentanyl, with 100 mcg in 2 patients. A CT scan was performed in these 2 patients, showing serositis in 1 and no abnormalities in the other. Predictors of PP were lesion size (35 mm, IQR 25-40, in the group without pain versus 40 mm, IQR 30-50, pZ.024), Paris 0-IIa+Is (29.4% in the group without pain versus 48.4%, pZ.01) and intra-procedural bleeding requiring endoscopic control (51% in the group without pain versus 73.3%, pZ.032). Lesion size 45mm was the only independent variable on multivariate analysis with an odds
www.giejournal.org
Mo1086 Severity of Gastrointestinal Bleeding in Patients Treated With Direct-Acting Oral Anticoagulants (DOACS) Mark M. Brodie*, Tyler Smith, Jill Newman, Don C. Rockey Medical University of South Carolina, Charleston, SC Background: Direct-acting oral anticoagulants (DOACs), which have recently been approved for stroke prevention in non-valvular atrial fibrillation and treatment of venous thromboembolism, have become increasingly preferred over warfarin given their predictable pharmacodynamics and lack of required monitoring. DOACs have been shown to be associated with an increased frequency of gastrointestinal bleeding (GIB) compared to warfarin, but the severity of GIB in these patients is poorly understood. Methods: We retrospectively evaluated medical records of patients with diagnosis codes of GIB (nZ8,496) from 2010-2016. We identified 61 patients with GIB episodes while treated with DOACs (rivaroxaban, dabigatran, or apixaban) and 119 patients with GIB while on warfarin. We randomly selected a control group of 242 patients with GIB on no anticoagulation from the same data set. Outcomes included hospitalizations, blood transfusions, GIB requiring either endoscopic or surgical intervention, and 30-day mortality. Results: The DOAC, warfarin, and control groups were similar in terms of age and underlying comorbidity (Charlson Comorbidity Index). The DOAC group had more concomitant aspirin use than the warfarin group (Table 1). GIB was classified as upper (nZ166), lower (nZ69), anorectal (nZ168), and other (nZ19). The DOAC group had a trend toward fewer hospitalizations (51% vs 64%, pZ0.07) and required transfusions less frequently (28% vs 42%, pZ0.04) compared with the warfarin group (Table 2). The DOAC and control groups were similar with regard to hospitalizations and blood transfusions. There were no significant differences between any groups in 30-day mortality or need for intervention. Conclusion: Although prior studies have shown a higher frequency of GIB in patients treated with DOACs compared to warfarin, our data suggest that the severity of GIB in patients taking DOACs may be less, with fewer transfusions and a trend toward fewer hospitalizations. This was despite significantly greater concomitant aspirin use in the DOAC group.
Table 1 Demographic and Clinical Features
Control (n[242)
DOAC (n[61)
Warfarin (n[119)
Age (Years, Mean +/- SD) Female Caucasian African American Other Race Charlson Comorbidity Index (Mean +/- SD) Concomitant Aspirin Use
63 +/- 13 46% 46% 52% 1.7% 4.0 +/- 2.5 47%
68 +/- 13 38% 79% 21% 0% 4.5 +/- 2.0 43%
66 +/- 14 59% 52% 46% 2.5% 4.4 +/- 2.1 14%
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB421