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Mo1557 Opioid Use Is Not Associated With Incomplete Studies or Prolonged Transit Times in Ambulatory Patients Receiving Wireless Capsule Endoscopy
Abstracts
undergo further post-VCE diagnostic evaluations (p!0.0001). Conclusion: Older age, overt bleeding (specifically the presence of melena), inpatient status, and total units of PRBCs transfused were independent predictors of a clinically significant finding on VCE. In patients with such characteristics, VCE should be utilized earlier and more frequently in hopes of avoiding unnecessary procedures and guiding more precise therapeutic interventions.
the ambulatory setting was not associated with prolonged transit time or a higher rate of incomplete studies. Given these findings, we do not recommend altering stable outpatient opioid regimens prior to WCE. This also supports the continued use of the standard 8 hour battery as opposed to an extended battery life WCE in this patient population.
Table 1. Transit time and Completion Results Table 1. Predictors of Clinically Significant Finding on VCE
Parameter Age, mean (SD) Coumadin, no. (%) ESRD, no. (%) Inpatient, no. (%) Overt Bleed, no. (%) Reason for VCE, no. (%) IDA Anemia NOS Hematochezia Melena Mix Prior CE/PE/DBE, no. (%) PRBC Transfusions^, no. (%) Zero 1-3 O3 Post-VCE Workup, no. (%)
Significant Finding (n [ 177)
Non-Significant Finding (n [ 107)
65.5 (12.4) 27 (16) 15 (9) 75 (42) 99 (56) 46 (26) 31 (17) 24 (14) 71 (40) 6 (3)
58.2 (14.5) 9 (9) 3 (3) 31 (29) 43 (42) 40 (38) 19 (18) 18 (17) 22 (21) 7 (7)
!0.0001* 0.098 0.066 0.030* 0.024* 0.013*
44 (26) 61 (37) 48 (29) 55 (34)
17 (17) 57 (57) 22 (22) 20 (20)
0.091 0.005*
68 (38)
7 (7)
!0.0001*
P value
VCE, video capsule endoscopy; SD, standard deviation; ESRD, end stage renal disease; IDA, iron deficiency anemia; NOS, not otherwise specified; PE, push enteroscopy; DBE, double balloon enteroscopy; PRBC, packed red blood cell. *Indicates P-values that are significant at the 95% significance level (p!0.05)^PRBC Transfusions were only in the last month prior to the VCE
Mo1557 Opioid Use Is Not Associated With Incomplete Studies or Prolonged Transit Times in Ambulatory Patients Receiving Wireless Capsule Endoscopy Bryan M. Kleinman*1, Peter P. Stanich2, Kavita Betkerur3, Kyle Porter4, Marty M. Meyer2 1 Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 2Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH; 3College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 4Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH Background: Wireless capsule endoscopy (WCE) is a commonly used procedure for visualization of the small bowel. For a study to be considered complete, the WCE must reach the colon during the battery life. Opioids have variably been linked with incomplete studies and prolonged transit times in previous studies that have investigated potential causes of incomplete WCE in heterogeneous cohorts. To our knowledge, none have examined solely outpatient WCE. Aim: To investigate the effect of opioids on bowel transit time and completion rate in ambulatory patients undergoing WCE at a high volume tertiary care center. Methods: We performed a retrospective review of all ambulatory patients undergoing WCE from 4/2010 - 3/2013. Exclusion criteria included endoscopic placement and lack of adequate medication records. Demographic data, medical history, medications and indication for WCE were collected from the medical record. Gastric transit time (GTT), small bowel transit time, total transit time (TTT) and study completion were collected from the WCE report. Transit times were summarized using median and inter-quartile range (IQR) and compared by log-rank analysis. Multivariable logistic regression modeling was utilized with resultant odds ratios (OR) and 95% confidence intervals (95% CI). Results: We performed a total of 314 ambulatory WCE that met criteria during the study period. Of these, 89 (28%) patients had opioid use within 24 hours of the procedure. Patients without opioids within 24 hours of WCE had a median TTT of 252 minutes (IQR 185-323) as compared to 261 minutes (IQR 183-363) in patients who had received opioids (pZ0.64). GTT was also similar between the two groups with a median GTT of 25 minutes (IQR 14-54) in the group not receiving opioids within 24 hours as compared to 24 minutes (IQR 10-69) in the group receiving opioids (pZ0.47). Completion rates were similar between the groups (88% and 87%, respectively). There were similar rates of gastric capsule retention (defined as WCE not leaving the stomach during battery life). There was one WCE retention event (defined as WCE remaining in bowel at 14 days) in the cohort without opioids. There was not a significant difference in the number of arteriovenous malformations detected. There was an increased incidence of prior bariatric surgery (pZ0.03) and Crohn’s disease (pZ0.002) in the group receiving opioids. Demographic data and medical history were otherwise similar. Conclusions: Opioid use within 24 hours of WCE in
AB376 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
Patients Gastric transit time Small intestine transit time Total transit time Completed study, n (%) Gastric capsule retention, n (%)
No Opioids 24 hours
Opioids 24 hours
p-value
n Z 225 25 (14, 54) 213 (142, 279) 252 (185, 323) 197 (88%) 9 (4%)
n Z 89 24 (10, 69) 206 (125, 305) 261 (183, 363) 77 (87%) 3 (3%)
0.47 0.62 0.64 0.80 0.79
*Transit times expressed as median in minutes with IQR.
Mo1558 Diagnostic Yield of CT Enterography in Evaluation of Obscure GI Bleeding in Comparison With Small Bowel Capsule Endoscopy in Clinical Practice Hari P. Sayana1, Heather Andrews*2, Aditya Gutta2, Saiprasad Narsingam2, Stephen Simon3, Fadi Bdair1 1 Gastroenterology and Hepatology, University of Missouri - Kansas City, Kansas City, MO; 2Internal Medicine, University of Missouri- Kansas City, Kansas City, MO; 3Biomedical and Health Informatics, University of Missouri- Kansas City, Kansas City, MO Background: CT enterography and small bowel capsule endoscopy are commonly used modalities in the evaluation of obscure GI bleeding. Although CT enterography has showed comparable yield to that of capsule endoscopy, its diagnostic yield in clinical practice does not meet these expectations. Aim: The aim of this study is to evaluate the diagnostic yield of CT enterography in the evaluation of patients with obscure GI bleeding in clinical practice in comparison to capsule endoscopy. Methods: We reviewed the medical records of all patients that presented with obscure overt or occult GI bleeding that had undergone CT enterography from January 2008 to October 2013. Three investigators collected pertinent data. Inclusion criteria include adult patients O18 years of age, with suspected obscure occult or overt GI bleeding, with negative work up including EGD and colonoscopy. Patients with past medical history of inflammatory bowel disease, chronic kidney disease, and chronic liver disease were excluded. Results: A total of 98 patients met the inclusion criteria. The mean age was 57 year 12 with 51% (50/98) females, 51% African American and 39% Caucasian. Thirty nine percent (nZ38/98) presented with iron deficiency anemia and suspected obscure occult bleeding and the rest presented with obscure overt bleeding. All patients underwent CT enterography and 43 patients (44%) followed up with small bowel capsule endoscopy. Inpatient capsule endoscopy was performed in 6 patients with obscure overt bleeding and the rest were performed as an outpatient. CT enterography was non-diagnostic in 96 patients (97.9%) and two patients had false positive findings. One of the false positive finding was a suspected hemorrhagic lesion in cecum and the other was a high attenuating lesion in the rectum. Both were found to be negative on endoscopy from the same day. The diagnostic yield of capsule endoscopy was 67.4% (29/43) with the majority finding small bowel AVMs (89%, nZ26) the others include small bowel ulcer in 2 and distal small bowel polyp in 1 patient with stigmata of recent bleeding. Small bowel capsule endoscopy was incomplete in 3 patients where it did not reach the colon during recording time but no capsule retention was reported. Conclusion: CT enterography is an over utilized modality with a poor diagnostic yield in clinical practice when compared to small bowel capsule endoscopy in evaluation of obscure GI bleeding. In the era of health care savings and patient safety (radiation risk), capsule endoscopy should be the initial test of choice especially when suspicion for intestinal obstruction is low.
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undergo further post-VCE diagnostic evaluations (p!0.0001). Conclusion: Older age, overt bleeding (specifically the presence of melena), inpatient status, and total units of PRBCs transfused were independent predictors of a clinically significant finding on VCE. In patients with such characteristics, VCE should be utilized earlier and more frequently in hopes of avoiding unnecessary procedures and guiding more precise therapeutic interventions.
the ambulatory setting was not associated with prolonged transit time or a higher rate of incomplete studies. Given these findings, we do not recommend altering stable outpatient opioid regimens prior to WCE. This also supports the continued use of the standard 8 hour battery as opposed to an extended battery life WCE in this patient population.
Table 1. Transit time and Completion Results Table 1. Predictors of Clinically Significant Finding on VCE
Parameter Age, mean (SD) Coumadin, no. (%) ESRD, no. (%) Inpatient, no. (%) Overt Bleed, no. (%) Reason for VCE, no. (%) IDA Anemia NOS Hematochezia Melena Mix Prior CE/PE/DBE, no. (%) PRBC Transfusions^, no. (%) Zero 1-3 O3 Post-VCE Workup, no. (%)
Significant Finding (n [ 177)
Non-Significant Finding (n [ 107)
65.5 (12.4) 27 (16) 15 (9) 75 (42) 99 (56) 46 (26) 31 (17) 24 (14) 71 (40) 6 (3)
58.2 (14.5) 9 (9) 3 (3) 31 (29) 43 (42) 40 (38) 19 (18) 18 (17) 22 (21) 7 (7)
!0.0001* 0.098 0.066 0.030* 0.024* 0.013*
44 (26) 61 (37) 48 (29) 55 (34)
17 (17) 57 (57) 22 (22) 20 (20)
0.091 0.005*
68 (38)
7 (7)
!0.0001*
P value
VCE, video capsule endoscopy; SD, standard deviation; ESRD, end stage renal disease; IDA, iron deficiency anemia; NOS, not otherwise specified; PE, push enteroscopy; DBE, double balloon enteroscopy; PRBC, packed red blood cell. *Indicates P-values that are significant at the 95% significance level (p!0.05)^PRBC Transfusions were only in the last month prior to the VCE
Mo1557 Opioid Use Is Not Associated With Incomplete Studies or Prolonged Transit Times in Ambulatory Patients Receiving Wireless Capsule Endoscopy Bryan M. Kleinman*1, Peter P. Stanich2, Kavita Betkerur3, Kyle Porter4, Marty M. Meyer2 1 Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 2Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH; 3College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 4Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH Background: Wireless capsule endoscopy (WCE) is a commonly used procedure for visualization of the small bowel. For a study to be considered complete, the WCE must reach the colon during the battery life. Opioids have variably been linked with incomplete studies and prolonged transit times in previous studies that have investigated potential causes of incomplete WCE in heterogeneous cohorts. To our knowledge, none have examined solely outpatient WCE. Aim: To investigate the effect of opioids on bowel transit time and completion rate in ambulatory patients undergoing WCE at a high volume tertiary care center. Methods: We performed a retrospective review of all ambulatory patients undergoing WCE from 4/2010 - 3/2013. Exclusion criteria included endoscopic placement and lack of adequate medication records. Demographic data, medical history, medications and indication for WCE were collected from the medical record. Gastric transit time (GTT), small bowel transit time, total transit time (TTT) and study completion were collected from the WCE report. Transit times were summarized using median and inter-quartile range (IQR) and compared by log-rank analysis. Multivariable logistic regression modeling was utilized with resultant odds ratios (OR) and 95% confidence intervals (95% CI). Results: We performed a total of 314 ambulatory WCE that met criteria during the study period. Of these, 89 (28%) patients had opioid use within 24 hours of the procedure. Patients without opioids within 24 hours of WCE had a median TTT of 252 minutes (IQR 185-323) as compared to 261 minutes (IQR 183-363) in patients who had received opioids (pZ0.64). GTT was also similar between the two groups with a median GTT of 25 minutes (IQR 14-54) in the group not receiving opioids within 24 hours as compared to 24 minutes (IQR 10-69) in the group receiving opioids (pZ0.47). Completion rates were similar between the groups (88% and 87%, respectively). There were similar rates of gastric capsule retention (defined as WCE not leaving the stomach during battery life). There was one WCE retention event (defined as WCE remaining in bowel at 14 days) in the cohort without opioids. There was not a significant difference in the number of arteriovenous malformations detected. There was an increased incidence of prior bariatric surgery (pZ0.03) and Crohn’s disease (pZ0.002) in the group receiving opioids. Demographic data and medical history were otherwise similar. Conclusions: Opioid use within 24 hours of WCE in
AB376 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014
Patients Gastric transit time Small intestine transit time Total transit time Completed study, n (%) Gastric capsule retention, n (%)
No Opioids 24 hours
Opioids 24 hours
p-value
n Z 225 25 (14, 54) 213 (142, 279) 252 (185, 323) 197 (88%) 9 (4%)
n Z 89 24 (10, 69) 206 (125, 305) 261 (183, 363) 77 (87%) 3 (3%)
0.47 0.62 0.64 0.80 0.79
*Transit times expressed as median in minutes with IQR.
Mo1558 Diagnostic Yield of CT Enterography in Evaluation of Obscure GI Bleeding in Comparison With Small Bowel Capsule Endoscopy in Clinical Practice Hari P. Sayana1, Heather Andrews*2, Aditya Gutta2, Saiprasad Narsingam2, Stephen Simon3, Fadi Bdair1 1 Gastroenterology and Hepatology, University of Missouri - Kansas City, Kansas City, MO; 2Internal Medicine, University of Missouri- Kansas City, Kansas City, MO; 3Biomedical and Health Informatics, University of Missouri- Kansas City, Kansas City, MO Background: CT enterography and small bowel capsule endoscopy are commonly used modalities in the evaluation of obscure GI bleeding. Although CT enterography has showed comparable yield to that of capsule endoscopy, its diagnostic yield in clinical practice does not meet these expectations. Aim: The aim of this study is to evaluate the diagnostic yield of CT enterography in the evaluation of patients with obscure GI bleeding in clinical practice in comparison to capsule endoscopy. Methods: We reviewed the medical records of all patients that presented with obscure overt or occult GI bleeding that had undergone CT enterography from January 2008 to October 2013. Three investigators collected pertinent data. Inclusion criteria include adult patients O18 years of age, with suspected obscure occult or overt GI bleeding, with negative work up including EGD and colonoscopy. Patients with past medical history of inflammatory bowel disease, chronic kidney disease, and chronic liver disease were excluded. Results: A total of 98 patients met the inclusion criteria. The mean age was 57 year 12 with 51% (50/98) females, 51% African American and 39% Caucasian. Thirty nine percent (nZ38/98) presented with iron deficiency anemia and suspected obscure occult bleeding and the rest presented with obscure overt bleeding. All patients underwent CT enterography and 43 patients (44%) followed up with small bowel capsule endoscopy. Inpatient capsule endoscopy was performed in 6 patients with obscure overt bleeding and the rest were performed as an outpatient. CT enterography was non-diagnostic in 96 patients (97.9%) and two patients had false positive findings. One of the false positive finding was a suspected hemorrhagic lesion in cecum and the other was a high attenuating lesion in the rectum. Both were found to be negative on endoscopy from the same day. The diagnostic yield of capsule endoscopy was 67.4% (29/43) with the majority finding small bowel AVMs (89%, nZ26) the others include small bowel ulcer in 2 and distal small bowel polyp in 1 patient with stigmata of recent bleeding. Small bowel capsule endoscopy was incomplete in 3 patients where it did not reach the colon during recording time but no capsule retention was reported. Conclusion: CT enterography is an over utilized modality with a poor diagnostic yield in clinical practice when compared to small bowel capsule endoscopy in evaluation of obscure GI bleeding. In the era of health care savings and patient safety (radiation risk), capsule endoscopy should be the initial test of choice especially when suspicion for intestinal obstruction is low.
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