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Sa1492 Diagnostic Yield of Single Versus Double Endoscopic Examinations in Chronic Graft-Versus-Host-Disease (GVHD)
Abstracts
Sa1492 Diagnostic Yield of Single Versus Double Endoscopic Examinations in Chronic Graft-Versus-Host-Disease (GVHD) Daena Watcha1, Anne Liu2, Laura Johnston3, Lauren B. Gerson*4,2 1 Epidemiology, Stanford University, Stanford, CA; 2Medicine, Stanford University, Stanford, CA; 3Bone and Marrow Transplantation, Stanford University, Stanford, CA; 4Gastroenterology, Stanford University, Redwood City, CA Background: GI manifestations of chronic graft-versus-host disease (GVHD) cause significant morbidity and mortality. There has been debate regarding the utility of double versus single endoscopic examinations, optimal sites of biopsy, and whether symptoms should dictate the type of endoscopic examination performed. Methods: We performed a case-control study of 23 chronic GI-GVHD cases and 48 controls who underwent single (upper endoscopy (EGD), sigmoidoscopy (SIG), or colonoscopy (COLO)) or double (EGD plus either SIG or COLO) endoscopic procedures at least 100 days post-bone marrow transplantation between 1/2000-9/2011. We selected patients who did not have a prior diagnosis of acute GVHD, as determined by the Glucksburg criteria. Chronic GI-GVHD status was determined by the Seattle criteria. The NIH criteria were used as of 2008. Chart verification was performed to document that the patient underwent treatment with high dose steroids (corticosteroids ⬎1 mg/kg). We collected data regarding symptoms at presentation, type of endoscopic examination performed, endoscopic findings (Cruz-Correa, Endoscopy 2002), sites of biopsy, and results of pathology examinations. Results: The GI-GVHD cases underwent 23 total endoscopic examinations including 13 (57%) double and 10 (43%) single procedures. The controls underwent 67 endoscopies including 14 (21%) double and 53 (79%) single procedures. Performance of bidirectional endoscopic examination demonstrated a positive association with diagnostic yield for chronic GVHD (p⫽0.001, Table 1). Symptoms leading to endoscopic examinations included diarrhea, abdominal pain, nausea, anorexia, vomiting, dysphagia, melena, failure to thrive, and GERD. The presence of diarrhea was associated with the finding of GVHD (p⫽0.001, Table 2). The diagnostic yield of double endoscopy alone (based on endoscopic findings without pathology) was 85% compared to 78% for lower endoscopy and 61% for EGD (p⫽0.3). The diagnostic yield of double endoscopy with biopsy was 92%, compared to 72% for EGD only and 83% for lower endoscopy alone (p⫽0.4). For the EGD examinations, biopsy at the duodenum gave the highest diagnostic yield at 92% (p⫽0.008 compared to gastric biopsies). In lower endoscopic examination, there was no significant difference between biopsies obtained from the right colon (terminal ileum, cecum and ascending colon, yield of 61%) and the left colon (descending colon, sigmoid and rectum, yield of 77%, p⫽NS). Overall, ⬎ 99% of patients with chronic GVHD had similar pathologic findings to those found in acute GVHD. Conclusion: The presence of diarrhea, but not nausea or abdominal pain, was positively associated with a diagnosis of chronic GVHD. The diagnostic yield was highest in patients undergoing both upper and full colonoscopic examinations with biopsies. Table 1. Yield of Endoscopic Examinations Endoscopic Examination Double Endoscopy Lower EndoscopyOnly EGD Only EGD⫹Colo EGG⫹SIG COLO only SIG only
Patients with GI-GVHD (Nⴝ23)
Patients without GI-GVHD (Nⴝ67)
P value
13 5 5 12 1 5 0
14 16 37 11 3 15 1
0.001 NS 0.007 0.002 NS NS NS
Sigmoid colon Rectum Random colon Lower Endoscopy Aggregate Right Colon (transverse ileum, cecum, ascending colon) Left Colon (descending colon, sigmoid colon, rectum)
Patients with GI-GVHD (Nⴝ23)
Patients without GI-GVHD (Nⴝ67)
P value
4 3 5
5 4 6
80% 75% 83%
11
18
61%
10
13
77%
Sa1493 Increasing Use of Colonoscopy and Endoscopic Treatment Over a Decade Associated With Increased Prevalence of Colorectal Tumors and Complications in the Elderly Taro Osada*, Naoto Sakamoto, Kentaro Izumi, Tomohiro Kodani, Tomoyoshi Shibuya, Kenshi Matsumoto, Akihito Nagahara, Tatsuo Ogihara, Sumio Watanabe Gastroenterology, Juntendo university school of medicine., Tokyo, Japan Objective: The advancement of endoscopic technology has brought an increase in colonoscopic examinations and endoscopic treatment of colorectal tumors in individuals over 80 years old. Endoscopic submucosal dissection (ESD) is indicated for the treatment of large early-stage superficial colorectal carcinoma even in elderly patients. In this study, we examined the change in incidence of neoplastic lesions between the recent three years and a three-year period ten years earlier, and analyzed the complications after colorectal ESD in elderly patients. Method: A total of 10,516 patients who were admitted to our hospital for colonoscopic examinations from 2009 to 2011 were enrolled and compared with 8,767 historical cases from 1999 to 2001. The rate of patients over 80 years old and the prevalence of neoplastic lesions were analyzed in each period. Additionally, 199 patients who underwent colorectal ESD for laterally spreading tumors (LST) larger than 2cm from April 2006 were enrolled. We analyzed the relationship between post-ESD fever and the age of patients, as well as other features of post-ESD fever. Results: Compared to the 10-year-old results, in the recent study period the rate of patients over 80 years old was significantly increased from 2.86% (251cases) to 5.40% (568 cases) (p⬍0.001, chi-square test), and the rate of elderly patients who had colorectal adenoma was also increased from 2.95% (109 cases) to 6.54% (242 cases) (p⬍0.001, chi-square test). In the recent three years, the prevalence of colorectal adenoma was 42.3% (242 cases) in patients over 80 years old and 34.8% (3457 cases) in those under 80 years old, which was a significant age-dependent increase (p⬍0.001, chi-square test). The prevalence of advanced colorectal carcinoma was 3.35% (19 cases) and 1.48% (147 cases) in the over 80 and under 80 age groups, respectively, for the same period. Post-ESD fever (body temperature ⱖ37 C) was the most common complication of colorectal ESD. The incidence of post-ESD fever was 44.5% and 70.6% (p⫽0.039 chi-square test) in patients aged under 80 years and over 80 years, respectively. Logistic regression analysis of post-ESD fever incidence showed (odds ratios) that age, 1.05 (95% CI [1.01-1.08] p⫽0.005) and lesion size, 1.05 (95% CI [1.02-1.08] p⫽0.0003) were closely associated with post-ESD fever, but gender, form, location and intraoperative perforation were not. The mean duration of post-ESD fever was 3.3 days, for a maximum of 13 days. Conclusions: With the increasing frequency of colonoscopic examinations of patients over 80 years old, the incidence of detected neoplastic lesions had increased significantly after a decade. It is predicted that complications from endoscopic treatment of elderly patients will increase in succeeding years. Extra care is required for elderly patients during and after endoscopic treatment.
COLO⫽colonoscopy; SIG⫽flexible sigmoidoscopy; EGD⫽upper endoscopy Table 2. Indications for Endoscopy and Diagnostic Yields
Diarrhea Nausea Abdominal pain
Upper Endoscopy Esophagus Stomach Duodenum Lower Endoscopy Terminal ileum Cecum Ascending colon Transverse colon Descending colon
www.giejournal.org
Patients with GI-GVHD (Nⴝ23)
Patients without GI-GVHD (Nⴝ67)
16 (70%) 8 (35%) 7 (30%) BIopsy ⫹ GVHD
19 (28%) 18 (27%) 11 (16%) Number of Biopsies
0.001 NS NS Percent
1 7 11
4 10 12
25% 70% 92%
5 2 4 6 3
7 4 8 4 5
71% 50% 57% 75% 75%
P value
Sa1494 Colonoscopy in Very Old Hospitalized Patients With Symptoms: Is It the First Choice? Sergio Segato*, Alessandra Baccarin, Marco Parravicini, Giada Bisso, Claudio C. Cortelezzi, Gian Luca Rotabacchetta Gastroenterology, Macchi Hospital, Varese, Italy Background and Aim: Data from the literature support the use of colonoscopy for diagnosis and treatment of findings in elderly patients with symptoms. Data about very old people in inpatient settings are few and often controversial. The aim of the study was to investigate outcomes of colonoscopy in these patients. Materials and Methods: The study was made on 193 consecutive patients over 85 years (104 women, 89 men, medium age 86.5, range 85-95 years), who performed colonoscopy for symptoms (anemia, hematochezia, altered bowel habits, abdominal pain) during hospitalization in Macchi Hospital Varese between January and December 2011 (Group A). In the same way, colonoscopy was made on 193 symptomatic consecutive younger patients (81 women, 112 men, medium age 57 years range 14-70) as a control group (Group B).All patients underwent routine pre-colonoscopy preparation with macrogol 3350
Volume 77, No. 5S : 2013
GASTROINTESTINAL ENDOSCOPY
AB225
Sa1492 Diagnostic Yield of Single Versus Double Endoscopic Examinations in Chronic Graft-Versus-Host-Disease (GVHD) Daena Watcha1, Anne Liu2, Laura Johnston3, Lauren B. Gerson*4,2 1 Epidemiology, Stanford University, Stanford, CA; 2Medicine, Stanford University, Stanford, CA; 3Bone and Marrow Transplantation, Stanford University, Stanford, CA; 4Gastroenterology, Stanford University, Redwood City, CA Background: GI manifestations of chronic graft-versus-host disease (GVHD) cause significant morbidity and mortality. There has been debate regarding the utility of double versus single endoscopic examinations, optimal sites of biopsy, and whether symptoms should dictate the type of endoscopic examination performed. Methods: We performed a case-control study of 23 chronic GI-GVHD cases and 48 controls who underwent single (upper endoscopy (EGD), sigmoidoscopy (SIG), or colonoscopy (COLO)) or double (EGD plus either SIG or COLO) endoscopic procedures at least 100 days post-bone marrow transplantation between 1/2000-9/2011. We selected patients who did not have a prior diagnosis of acute GVHD, as determined by the Glucksburg criteria. Chronic GI-GVHD status was determined by the Seattle criteria. The NIH criteria were used as of 2008. Chart verification was performed to document that the patient underwent treatment with high dose steroids (corticosteroids ⬎1 mg/kg). We collected data regarding symptoms at presentation, type of endoscopic examination performed, endoscopic findings (Cruz-Correa, Endoscopy 2002), sites of biopsy, and results of pathology examinations. Results: The GI-GVHD cases underwent 23 total endoscopic examinations including 13 (57%) double and 10 (43%) single procedures. The controls underwent 67 endoscopies including 14 (21%) double and 53 (79%) single procedures. Performance of bidirectional endoscopic examination demonstrated a positive association with diagnostic yield for chronic GVHD (p⫽0.001, Table 1). Symptoms leading to endoscopic examinations included diarrhea, abdominal pain, nausea, anorexia, vomiting, dysphagia, melena, failure to thrive, and GERD. The presence of diarrhea was associated with the finding of GVHD (p⫽0.001, Table 2). The diagnostic yield of double endoscopy alone (based on endoscopic findings without pathology) was 85% compared to 78% for lower endoscopy and 61% for EGD (p⫽0.3). The diagnostic yield of double endoscopy with biopsy was 92%, compared to 72% for EGD only and 83% for lower endoscopy alone (p⫽0.4). For the EGD examinations, biopsy at the duodenum gave the highest diagnostic yield at 92% (p⫽0.008 compared to gastric biopsies). In lower endoscopic examination, there was no significant difference between biopsies obtained from the right colon (terminal ileum, cecum and ascending colon, yield of 61%) and the left colon (descending colon, sigmoid and rectum, yield of 77%, p⫽NS). Overall, ⬎ 99% of patients with chronic GVHD had similar pathologic findings to those found in acute GVHD. Conclusion: The presence of diarrhea, but not nausea or abdominal pain, was positively associated with a diagnosis of chronic GVHD. The diagnostic yield was highest in patients undergoing both upper and full colonoscopic examinations with biopsies. Table 1. Yield of Endoscopic Examinations Endoscopic Examination Double Endoscopy Lower EndoscopyOnly EGD Only EGD⫹Colo EGG⫹SIG COLO only SIG only
Patients with GI-GVHD (Nⴝ23)
Patients without GI-GVHD (Nⴝ67)
P value
13 5 5 12 1 5 0
14 16 37 11 3 15 1
0.001 NS 0.007 0.002 NS NS NS
Sigmoid colon Rectum Random colon Lower Endoscopy Aggregate Right Colon (transverse ileum, cecum, ascending colon) Left Colon (descending colon, sigmoid colon, rectum)
Patients with GI-GVHD (Nⴝ23)
Patients without GI-GVHD (Nⴝ67)
P value
4 3 5
5 4 6
80% 75% 83%
11
18
61%
10
13
77%
Sa1493 Increasing Use of Colonoscopy and Endoscopic Treatment Over a Decade Associated With Increased Prevalence of Colorectal Tumors and Complications in the Elderly Taro Osada*, Naoto Sakamoto, Kentaro Izumi, Tomohiro Kodani, Tomoyoshi Shibuya, Kenshi Matsumoto, Akihito Nagahara, Tatsuo Ogihara, Sumio Watanabe Gastroenterology, Juntendo university school of medicine., Tokyo, Japan Objective: The advancement of endoscopic technology has brought an increase in colonoscopic examinations and endoscopic treatment of colorectal tumors in individuals over 80 years old. Endoscopic submucosal dissection (ESD) is indicated for the treatment of large early-stage superficial colorectal carcinoma even in elderly patients. In this study, we examined the change in incidence of neoplastic lesions between the recent three years and a three-year period ten years earlier, and analyzed the complications after colorectal ESD in elderly patients. Method: A total of 10,516 patients who were admitted to our hospital for colonoscopic examinations from 2009 to 2011 were enrolled and compared with 8,767 historical cases from 1999 to 2001. The rate of patients over 80 years old and the prevalence of neoplastic lesions were analyzed in each period. Additionally, 199 patients who underwent colorectal ESD for laterally spreading tumors (LST) larger than 2cm from April 2006 were enrolled. We analyzed the relationship between post-ESD fever and the age of patients, as well as other features of post-ESD fever. Results: Compared to the 10-year-old results, in the recent study period the rate of patients over 80 years old was significantly increased from 2.86% (251cases) to 5.40% (568 cases) (p⬍0.001, chi-square test), and the rate of elderly patients who had colorectal adenoma was also increased from 2.95% (109 cases) to 6.54% (242 cases) (p⬍0.001, chi-square test). In the recent three years, the prevalence of colorectal adenoma was 42.3% (242 cases) in patients over 80 years old and 34.8% (3457 cases) in those under 80 years old, which was a significant age-dependent increase (p⬍0.001, chi-square test). The prevalence of advanced colorectal carcinoma was 3.35% (19 cases) and 1.48% (147 cases) in the over 80 and under 80 age groups, respectively, for the same period. Post-ESD fever (body temperature ⱖ37 C) was the most common complication of colorectal ESD. The incidence of post-ESD fever was 44.5% and 70.6% (p⫽0.039 chi-square test) in patients aged under 80 years and over 80 years, respectively. Logistic regression analysis of post-ESD fever incidence showed (odds ratios) that age, 1.05 (95% CI [1.01-1.08] p⫽0.005) and lesion size, 1.05 (95% CI [1.02-1.08] p⫽0.0003) were closely associated with post-ESD fever, but gender, form, location and intraoperative perforation were not. The mean duration of post-ESD fever was 3.3 days, for a maximum of 13 days. Conclusions: With the increasing frequency of colonoscopic examinations of patients over 80 years old, the incidence of detected neoplastic lesions had increased significantly after a decade. It is predicted that complications from endoscopic treatment of elderly patients will increase in succeeding years. Extra care is required for elderly patients during and after endoscopic treatment.
COLO⫽colonoscopy; SIG⫽flexible sigmoidoscopy; EGD⫽upper endoscopy Table 2. Indications for Endoscopy and Diagnostic Yields
Diarrhea Nausea Abdominal pain
Upper Endoscopy Esophagus Stomach Duodenum Lower Endoscopy Terminal ileum Cecum Ascending colon Transverse colon Descending colon
www.giejournal.org
Patients with GI-GVHD (Nⴝ23)
Patients without GI-GVHD (Nⴝ67)
16 (70%) 8 (35%) 7 (30%) BIopsy ⫹ GVHD
19 (28%) 18 (27%) 11 (16%) Number of Biopsies
0.001 NS NS Percent
1 7 11
4 10 12
25% 70% 92%
5 2 4 6 3
7 4 8 4 5
71% 50% 57% 75% 75%
P value
Sa1494 Colonoscopy in Very Old Hospitalized Patients With Symptoms: Is It the First Choice? Sergio Segato*, Alessandra Baccarin, Marco Parravicini, Giada Bisso, Claudio C. Cortelezzi, Gian Luca Rotabacchetta Gastroenterology, Macchi Hospital, Varese, Italy Background and Aim: Data from the literature support the use of colonoscopy for diagnosis and treatment of findings in elderly patients with symptoms. Data about very old people in inpatient settings are few and often controversial. The aim of the study was to investigate outcomes of colonoscopy in these patients. Materials and Methods: The study was made on 193 consecutive patients over 85 years (104 women, 89 men, medium age 86.5, range 85-95 years), who performed colonoscopy for symptoms (anemia, hematochezia, altered bowel habits, abdominal pain) during hospitalization in Macchi Hospital Varese between January and December 2011 (Group A). In the same way, colonoscopy was made on 193 symptomatic consecutive younger patients (81 women, 112 men, medium age 57 years range 14-70) as a control group (Group B).All patients underwent routine pre-colonoscopy preparation with macrogol 3350
Volume 77, No. 5S : 2013
GASTROINTESTINAL ENDOSCOPY
AB225