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Sa1449 Diagnostic Yield of Colonoscopy With Random Colonic Biopsies in the Evaluation of Chronic Diarrhea
Abstracts
Sa1449 Diagnostic Yield of Colonoscopy With Random Colonic Biopsies in the Evaluation of Chronic Diarrhea Laura Pestana*, Michael Camilleri, Sunanda V. Kane Department of Medicine, Mayo Clinic, Rochester, MN Background: In the evaluation of patients with chronic diarrhea, colonoscopy with random colonic biopsies is recommended for those individuals in whom initial laboratory studies fail to generate a diagnosis. However, in outpatient open access endoscopy practice, demand for colonoscopy may exceed availability. Several reports have documented that chronic unexplained diarrhea without rectal bleeding (or functional diarrhea) may be due to celiac disease (w4%), bile acid malabsorption (25-40%) or disaccharidase deficiency. These conditions are typically not identified by colonoscopy or biopsies. In an effort to identify possible inappropriate use of colonoscopy and optimize access to the procedure for other indications, we evaluated the diagnostic yield of colonoscopy with random biopsy for patients with chronic diarrhea in an open access endoscopy practice at a tertiary care center. Methods: We searched the electronic medical records and endoscopic database for outpatients undergoing colonoscopy with biopsy procurement for the indication “diarrhea” or “change in bowel habit” over 18 months October 1, 2012 to May 23, 2014. Clinical data included gender, specialty of the referring physician, documentation of potential alarm symptoms (anemia, weight loss or bleeding) and results of colonic mucosal biopsies. Results: Five hundred forty three patients were identified. Sixty nine percent were female. Two-thirds of patients (63.2%) were referred by a gastroenterologist. Anemia was present in 83 patients (15.3%); presence of weight loss was inconsistently documented. Histologic abnormalities were noted in 130 patients (23.9%); microscopic colitis or other abnormalities leading to change in management occurred in only 100 (18%) patients. The majority of in the latter patients had been referred by a gastroenterologist. Conclusion: Colonoscopy with random colonic biopsies for the evaluation of chronic diarrhea failed to yield a histologic diagnosis for the majority of patients in a tertiary care open access endoscopy practice. These data suggest the need for enhancing the work up of diarrhea prior to ordering colonoscopy in an open access system to enhance care, and reduce the number of inappropriate procedures thereby improving access for truly indicated procedures.
Sa1450 Nurse-Administered Propofol in a Small Community GI Lab Is Associated With Short Procedure Times, Safety and High Cecum Intubation RATES Francisco E. Ramirez1, Snorri Olafsson*3, David Lively2, Neil Nedley1 1 Research, Nedley Clinic, Ardmore, OK; 2Mercy Hospital, Ardmore, OK; 3 Professor of Medicine, Loma Linda, Loma Linda, CA Background: From 1994 to 2012, after the state of Oklahoma and the nursing board approved the nurse-administered propofol as the main sedation method, nearly 50,000 endoscopic procedures were performed in a small community GI lab in the Midwest. Methods: We randomly sampled 1,011 endoscopic procedures done between 2010 and 2012 from the data base of the GI lab. The procedures were done by 6 trained physicians, 3 general surgeons, 1 gastroenterologist and 2 internists, with different years of experience as endoscopists. From the sample we counted only outpatient procedures. We eliminated 185 cases: 2 emergency endoscopies, 172 inpatients, 1 gastrostomy placement and those of one physician who had done only 10 cases. We ended up with 829 cases. We divided them into esophagogastroduodenoscopies (EGD), colonoscopies or both when done together. We used the physicians and nurses’ notes to capture the starting and ending time of the sedation of the procedures. All patients received propofol, at times complemented with midazolam and/or opioid. Results: The mean age of the 829 patients was 60.5 years. Table 1 shows different procedures, endoscopists, number of procedures, average time to do the procedure, standard deviation, amount of propofol used and, when applicable, crude cecal intubation rate. The cecum intubation rate was 97% for colonoscopies done alone but surprisingly only 83% when done following an EGD.Propofol was used in 99% of procedures, fentanyl in 26%, meperidine in 31% and midazolam in 94%. Fentanyl and meperidine were never used together. All the procedures where done without an anesthesiologist, the endoscopist dictated the amount and type of sedative used. Table 2 shows the drugs used during the proceduresThe longer the procedure the more propofol was used. The amount of fentanyl used was less for EGDs. Almost identical amount of meperidine was used for all three types of procedures. Less midazolam was used for EGDs but the amount was small for all procedures. Conclusion: The study shows that upper and lower endoscopies can be done with nurse-applied propofol. The propofol was supplemented in almost all cases by a small dose of midazolam and by an opiod in 57%. The mean and the median time for all types of procedures was low, which contributes to the efficiency of the GI lab. The crude cecum rate for colonoscopies done alone was very high for all the physicians even though most of them were nongastroenterologists. However, the cecum intubation rate was much lower when a colonoscopy was done following an EGD (83%) than when only a colonoscopy was done (97%). The reason for this is unknown. One theory is that air used during EGD may reach the colon making it longer with sharper turns.
www.giejournal.org
Sa1451 Development and Validation of the Saint Paul’s Endoscopy Comfort Scale (Specs) for Colonoscopy Oliver Takach*, Iran Tavakoli, Ricky W. Kwok, Natasha Harris, Jordan Yonge, Cherry E. Galorport, Scott Whittaker, Alnoor Ramji, Jack Amar, Greg Rosenfeld, Hin Hin Ko, Eric C. Lam, Brian Bressler, Jennifer J. Telford, Robert A. Enns University of British Columbia, Burnaby, BC, Canada Background: Patient comfort during colonoscopy is an important measure of colonoscopy quality and is associated with improved patient satisfaction and compliance with future procedures. The Gloucester Scale (GS) is the most commonly used; however, there are few studies evaluating its validity. AIM: We created the St. Paul’s Endoscopy Comfort Score (SPECS) which is a pain assessment tool based on objective behavioral cues tailored to outpatients undergoing colonoscopy and compared it to existing comfort scores in outpatients undergoing colonoscopy. Methods: Patients undergoing outpatient colonoscopy at St. Paul’s Hospital, Vancouver, BC, were prospectively enrolled between June and August 2014. Inclusion criteria: Age R 19 years and planned outpatient colonoscopy. Exclusion criteria: Non-English speaking, undergoing upper endoscopy (in addition to colonoscopy), and not completing the questionnaire. The SPECS and GS were completed by three independent staff: the physician, the nurse, and a research assistant. The research assistant also completed the Non-Verbal Pain Assessment Tool (NPAT) and Nurse Assessed Patient Comfort Score (NAPCOMS). Patient demographics, sedation dose, procedure duration, and the time spent in recovery were collected. Enrolled patients completed a patient satisfaction questionnaire and Visual Analogue Scale (VAS) that assessed the patient’s overall pain rating. Spearman rank coefficient analysis was used to assess the inter-rater variability amongst the observers and correlation between the different scales and the VAS. This study was approved by the IRB. Results: 350 subjects were recruited. SPECS was found to have the highest Spearman rank correlation when compared to the GS. Doctor vs nurse: rs Z 0.692 for GS and rs Z 0.773 for SPECS; nurse vs observer: rs Z 0.732 for GS and rs Z 0.828 for SPECS, and doctor vs observer: rs Z 0.794 for GS and rs Z 0.783 for SPECS. The Spearman coefficient comparing scales vs patient reported pain from the VAS showed: SPECS vs VAS: rs Z 0.515, GS vs VAS: rs Z 0.493, NAPCOMS vs VAS: rs Z 0.452, and NPAT vs VAS: rs Z 0.465. Conclusions: SPECS is a valid measure of patient comfort during colonoscopy. SPECS was more strongly correlated to patient pain recall and had superior inter-rater validity when compared to the GS.
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB221
Sa1449 Diagnostic Yield of Colonoscopy With Random Colonic Biopsies in the Evaluation of Chronic Diarrhea Laura Pestana*, Michael Camilleri, Sunanda V. Kane Department of Medicine, Mayo Clinic, Rochester, MN Background: In the evaluation of patients with chronic diarrhea, colonoscopy with random colonic biopsies is recommended for those individuals in whom initial laboratory studies fail to generate a diagnosis. However, in outpatient open access endoscopy practice, demand for colonoscopy may exceed availability. Several reports have documented that chronic unexplained diarrhea without rectal bleeding (or functional diarrhea) may be due to celiac disease (w4%), bile acid malabsorption (25-40%) or disaccharidase deficiency. These conditions are typically not identified by colonoscopy or biopsies. In an effort to identify possible inappropriate use of colonoscopy and optimize access to the procedure for other indications, we evaluated the diagnostic yield of colonoscopy with random biopsy for patients with chronic diarrhea in an open access endoscopy practice at a tertiary care center. Methods: We searched the electronic medical records and endoscopic database for outpatients undergoing colonoscopy with biopsy procurement for the indication “diarrhea” or “change in bowel habit” over 18 months October 1, 2012 to May 23, 2014. Clinical data included gender, specialty of the referring physician, documentation of potential alarm symptoms (anemia, weight loss or bleeding) and results of colonic mucosal biopsies. Results: Five hundred forty three patients were identified. Sixty nine percent were female. Two-thirds of patients (63.2%) were referred by a gastroenterologist. Anemia was present in 83 patients (15.3%); presence of weight loss was inconsistently documented. Histologic abnormalities were noted in 130 patients (23.9%); microscopic colitis or other abnormalities leading to change in management occurred in only 100 (18%) patients. The majority of in the latter patients had been referred by a gastroenterologist. Conclusion: Colonoscopy with random colonic biopsies for the evaluation of chronic diarrhea failed to yield a histologic diagnosis for the majority of patients in a tertiary care open access endoscopy practice. These data suggest the need for enhancing the work up of diarrhea prior to ordering colonoscopy in an open access system to enhance care, and reduce the number of inappropriate procedures thereby improving access for truly indicated procedures.
Sa1450 Nurse-Administered Propofol in a Small Community GI Lab Is Associated With Short Procedure Times, Safety and High Cecum Intubation RATES Francisco E. Ramirez1, Snorri Olafsson*3, David Lively2, Neil Nedley1 1 Research, Nedley Clinic, Ardmore, OK; 2Mercy Hospital, Ardmore, OK; 3 Professor of Medicine, Loma Linda, Loma Linda, CA Background: From 1994 to 2012, after the state of Oklahoma and the nursing board approved the nurse-administered propofol as the main sedation method, nearly 50,000 endoscopic procedures were performed in a small community GI lab in the Midwest. Methods: We randomly sampled 1,011 endoscopic procedures done between 2010 and 2012 from the data base of the GI lab. The procedures were done by 6 trained physicians, 3 general surgeons, 1 gastroenterologist and 2 internists, with different years of experience as endoscopists. From the sample we counted only outpatient procedures. We eliminated 185 cases: 2 emergency endoscopies, 172 inpatients, 1 gastrostomy placement and those of one physician who had done only 10 cases. We ended up with 829 cases. We divided them into esophagogastroduodenoscopies (EGD), colonoscopies or both when done together. We used the physicians and nurses’ notes to capture the starting and ending time of the sedation of the procedures. All patients received propofol, at times complemented with midazolam and/or opioid. Results: The mean age of the 829 patients was 60.5 years. Table 1 shows different procedures, endoscopists, number of procedures, average time to do the procedure, standard deviation, amount of propofol used and, when applicable, crude cecal intubation rate. The cecum intubation rate was 97% for colonoscopies done alone but surprisingly only 83% when done following an EGD.Propofol was used in 99% of procedures, fentanyl in 26%, meperidine in 31% and midazolam in 94%. Fentanyl and meperidine were never used together. All the procedures where done without an anesthesiologist, the endoscopist dictated the amount and type of sedative used. Table 2 shows the drugs used during the proceduresThe longer the procedure the more propofol was used. The amount of fentanyl used was less for EGDs. Almost identical amount of meperidine was used for all three types of procedures. Less midazolam was used for EGDs but the amount was small for all procedures. Conclusion: The study shows that upper and lower endoscopies can be done with nurse-applied propofol. The propofol was supplemented in almost all cases by a small dose of midazolam and by an opiod in 57%. The mean and the median time for all types of procedures was low, which contributes to the efficiency of the GI lab. The crude cecum rate for colonoscopies done alone was very high for all the physicians even though most of them were nongastroenterologists. However, the cecum intubation rate was much lower when a colonoscopy was done following an EGD (83%) than when only a colonoscopy was done (97%). The reason for this is unknown. One theory is that air used during EGD may reach the colon making it longer with sharper turns.
www.giejournal.org
Sa1451 Development and Validation of the Saint Paul’s Endoscopy Comfort Scale (Specs) for Colonoscopy Oliver Takach*, Iran Tavakoli, Ricky W. Kwok, Natasha Harris, Jordan Yonge, Cherry E. Galorport, Scott Whittaker, Alnoor Ramji, Jack Amar, Greg Rosenfeld, Hin Hin Ko, Eric C. Lam, Brian Bressler, Jennifer J. Telford, Robert A. Enns University of British Columbia, Burnaby, BC, Canada Background: Patient comfort during colonoscopy is an important measure of colonoscopy quality and is associated with improved patient satisfaction and compliance with future procedures. The Gloucester Scale (GS) is the most commonly used; however, there are few studies evaluating its validity. AIM: We created the St. Paul’s Endoscopy Comfort Score (SPECS) which is a pain assessment tool based on objective behavioral cues tailored to outpatients undergoing colonoscopy and compared it to existing comfort scores in outpatients undergoing colonoscopy. Methods: Patients undergoing outpatient colonoscopy at St. Paul’s Hospital, Vancouver, BC, were prospectively enrolled between June and August 2014. Inclusion criteria: Age R 19 years and planned outpatient colonoscopy. Exclusion criteria: Non-English speaking, undergoing upper endoscopy (in addition to colonoscopy), and not completing the questionnaire. The SPECS and GS were completed by three independent staff: the physician, the nurse, and a research assistant. The research assistant also completed the Non-Verbal Pain Assessment Tool (NPAT) and Nurse Assessed Patient Comfort Score (NAPCOMS). Patient demographics, sedation dose, procedure duration, and the time spent in recovery were collected. Enrolled patients completed a patient satisfaction questionnaire and Visual Analogue Scale (VAS) that assessed the patient’s overall pain rating. Spearman rank coefficient analysis was used to assess the inter-rater variability amongst the observers and correlation between the different scales and the VAS. This study was approved by the IRB. Results: 350 subjects were recruited. SPECS was found to have the highest Spearman rank correlation when compared to the GS. Doctor vs nurse: rs Z 0.692 for GS and rs Z 0.773 for SPECS; nurse vs observer: rs Z 0.732 for GS and rs Z 0.828 for SPECS, and doctor vs observer: rs Z 0.794 for GS and rs Z 0.783 for SPECS. The Spearman coefficient comparing scales vs patient reported pain from the VAS showed: SPECS vs VAS: rs Z 0.515, GS vs VAS: rs Z 0.493, NAPCOMS vs VAS: rs Z 0.452, and NPAT vs VAS: rs Z 0.465. Conclusions: SPECS is a valid measure of patient comfort during colonoscopy. SPECS was more strongly correlated to patient pain recall and had superior inter-rater validity when compared to the GS.
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB221