Sa1505 Predictive Factor of Colorectal Cancer for the Elderly Aged 85 Years and Older With Positive Fecal Occult Blood Test

Abstracts Sa1503 Effective Endoscopic Treatment of Mallory-Weiss Tear Using Glasgow-Blatchford Score and Forrest Classification Sunpyo Lee*, Ji Yong Ahn, Hwoon-Yong Jung, Jeong Hoon Lee, Kee Wook Jung, Kwi-Sook Choi, Do Hoon Kim, Kee Don Choi, Ho June Song, Gin Hyug Lee, Jin-Ho Kim Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea (the Republic of) Backgrounds and Aims: There have not been enough studies about the efficacy of Glasgow-Blatchford score (GBS), the usefulness of Forrest classification, and the proper methods of therapeutic endoscopy for Mallory-Weiss tear (MWT). In this study, we tried to investigate the clinical outcomes of MWT according to the GBS in predicting results at emergency room and the Forrest classification in deciding hemostasis during endoscopy, and the proper treatment modality for effective bleeding control. Patients and Methods: From January 2004 to December 2012, 168 patients were diagnosed as MWT by endoscopy at ER of Asan Medical Center. We retrospectively reviewed the medical records and endoscopic findings to calculate GBS, to estimate Forrest classification and to identify treatment modalities used for bleeding control. Results: Of total 168 patients, the median age was 49 years (interquartile range, 39 - 59 years) and men were 149 (88.7%), and mean GBS was 6.0 (4.3) points. Endoscopic hemostasis was applied to 88 cases (52.4%) and GBS was significantly higher in the hemostasis group than the observation group (6.83.7 and 5.14.7, respectively, pZ0.011). Forrest classification showed predictive power for endoscopic hemostasis with cut-off value between IIa and IIb. Grade I-IIa required endoscopic treatment and grade IIb-III could be managed with conservative treatment (area under the receiver operating characteristic curve Z 0.951, 95% CI 0.917 - 0.985, p!0.001). For the treatment of MWT, hemoclip with/without injection therapy was used in 56 patients (63.6%), band ligation alone was in 18 patients (20.5%), and injection therapy alone was in 14 patients (15.9%). Among 88 patients with endoscopic treatment, rebleeding happened in 8 cases (9.1%) and 2 patients with hepatic dysfunction died due to hemostasis failure. Success rates of treatment were higher in hemoclip-based therapy and band ligation than injection therapy alone (96.4%, 88.9%, and 71.4%,pZ.012). In patients with GBS more than 6 points, the rates of hemostasis, transfusion, admission, and rebleeding were higher with significance (p!0.05 in all factors). Conclusions: In non-variceal bleeding with MWT, GBS can be useful to predict clinical outcomes and Forrest classification can be helpful to decide the treatment with therapeutic endoscopy. For the endoscopic methods of MWT, injection therapy alone should be avoided for the better clinical results.

organizations used Cerner PowerNoteÒ and one used an in-house web application launched contextually through QuadraMed Computerized-Patient RecordÒ. For interoperability SNOMEDÒ Clinical Terms were incorporated. Results: Almost all endoscopists agreed the data model and endoscopy EMR supported timely communication, quality standards and improvement. There was some disagreement regarding the inclusion of standardized scoring systems, format and layout of the generated report and time required in comparison to unstructured dictation. Governance of the GI data model has been delegated to CAG with a mandate to continually refresh the elements and work with industry and international partners to create and maintain effective, affordable and sustainable endoscopy EMR systems.

University Health Network Clinical interface

Sa1504 “Shaken, Not Stirred.” Towards Standardized Synoptic Reporting in GI Endoscopy Electronic Medical Records (EMRs) Peter G. Rossos*1,2, Kelly Lane1, Stephen G. Holland5, Mary Lam1, Brent G. Mcgaw3, Robyn Sharma2, Jeremy Theal4 1 University Health Network, Toronto, ON, Canada; 2Medicine, University of Toronto, Toronto, ON, Canada; 3Canada Health Infoway, Toronto, ON, Canada; 4Medicine, North York General Hospital, North York, ON, Canada; 5Island Health, Victoria, BC, Canada Context: Canadian adoption of endoscopy EMRs remains low. Most current EMRs do not capture discreet standardized terminology, are difficult to configure and interface poorly with other systems. Data is difficult to extract and analyze for quality indicators, follow-up, research and performance management. Communication between endoscopists, referring MDs and patients is often delayed and of poor quality with inability to accurately assess providers, programs, resource matching and appropriateness of care. Cancer screening programs struggle to combine clinical, endoscopic and pathology details to provide recall and evaluate outcomes. The lack of enabling IT infrastructure is a barrier to delivering established national and international clinical best practices. Intervention:The Colonoscopy and Colposcopy Synoptic Reporting Project was funded by a Canada Health Infoway investment program to achieve national consensus pan-Canadian colonoscopy and colposcopy data models to support clinical best practice, develop and implement reporting templates using open technical solutions, establish governance to maintain and disseminate data models and work with industry to develop and implement effective and affordable solutions for the Canadian marketplace. The investigators established a National Endoscopist Working Group representing academic, community, adult and pediatric practice. Endoscopy reporting models consisting of data elements, quality and performance indicators were systematically developed through consensus and categorized as mandatory, recommended and for consideration. The group reviewed and incorporated elements and indicators from the Canadian Association of Gastroenterology (CAG) consensus guidelines on safety and quality indicators in endoscopy (January 2012), Clinical Outcomes Research Initiative (CORI), UK Global Rating Scale (GRS), Colonoscopy Reporting and Data System (CO-RADS) and Minimal Standard Terminology (MST). In the second phase five healthcare organizations implemented documentation templates based on the data models to evaluate adoption and benefits. Four

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Initial MD attitudes to EMR implementation.

Sa1505 Predictive Factor of Colorectal Cancer for the Elderly Aged 85 Years and Older With Positive Fecal Occult Blood Test Yutaka Hirayama*1,2, Osamu Watanabe1, Masanao Nakamura1, Takeshi Yamamura1, Hidemi Goto1 1 Departmant of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan; 2Department of Endoscopy, Tokai Central Hospital, Kakamigahara, Japan Introduction: Colorectal cancer (CRC) incidence ranks second among all cancers in Japan. Screening using the fecal occult blood test (FOBT) has been shown to reduce the incidence and mortality of CRC. Generally, ageing is known to be one of the risks of CRC. In addition, with population aging and the rising incidence of CRC worldwide, the incidence of CRC in the elderly is also expected to increase. However, the potential significance of FOBT and total colonoscopy for the elderly remain unclear. We conducted this study in an attempt to clarify the

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Abstracts

significance of positive FOBT and predictive factors of CRC with positive FOBT for the elderly aged R85 years. Methods: The records of consecutive 127 patients aged R85 years who tested FOBT positive and then underwent colonoscopy from January 2010 to September 2014 in Nagoya University Hospital and Tokai Central Hospital were reviewd. Uni- and multivariate logistic regression analyses were performed to describe the association. Results: 127 patients (M/F: 66/61) aged R85 years who tested FOBT(+) and underwent colonoscopy were enrolled. Median age at colonoscopy was 86.6 years (85-97years). Baseline characteristics of enrolled patients were 43 cases (33.9%) of hypertension or cardiovascular disease, 26 cases (20.5%) of malignancy, 21 cases (16.5%) of dementia, 19 cases (15.0%) of DM, 17 cases (13.4%) of CKD, 12 cases (9.4%) of COPD and 35 cases (27.6%) of antiplatelets or anticoagulants use (including overlapping cases). The cecal intubation rate was 94.5%. In terms of post colonoscopy complications, there was 1 case (0.8%) of perforation. The adenoma detection rate and prevalence of CRC were 37 cases (29.1%) and 12 cases (9.4%), respectively. The outcomes of enrolled patients were 30 cases of endoscopic resection, and 11 cases of surgery (including perforation case). Uni- and multivariate analysis using a logistic regression model identified presence of two or more sign or symptom among body weight loss, anemia, abd pain, appetite loss, and rectal bleeding at colonoscopy as a significant independent predictive factor for CRC in patients aged R85 years with positive FOBT (OR 13.8, 95%CI 2.8-66.8). There were no significant differences in sex ratio, age at colonoscopy, baseline characteristics, antiplatelets or aniticoagulants use, laboratory data at colposcopy, presence of one sign or symptom, past history of CRC or adenoma, past history of positive FOBT, and family history of CRC. Conclusion: The predictive factor that correlated with CRC in the elderly aged R85 years with positive FOBT was presence of two or more sign or symptom among body weight loss, anemia, abd pain, appetite loss, and rectal bleeding at colonoscopy.

Sa1506 A Cost-Utilization Analysis of Non-Hematemesis GIB Diagnostic Management Strategies Salmaan Jawaid*, Louise Maranda, Neil B. Marya, David R. Cave Univ of Massachusetts, Worcester, MA Introduction: Non-hematemesis gastrointestinal bleeding [NH GIB] can originate anywhere within the gastrointestinal tract. Current practice usually dictates an upper and lower endoscopy, followed by other procedures as needed. As a consequence, the diagnostic evaluation may incur unnecessary health care costs and diagnostic times. The use of a cost decision-analytical model of the current diagnostic management strategy applied to patients presenting with NH GIB may reveal alternative strategies for the evaluation of NH GIB. Methods: The model was designed to retrospectively follow the diagnostic course of 231 consecutive patients presenting with NHGIB to a tertiary care center emergency department [ED]. Calculations of total cost were based on cost of each esophagogastroduodenoscopy [EGD], colonoscopy [COLO], and video capsule endoscopy [VCE] plus the cost of pursuing secondary procedures after non-diagnostic primary procedures. Variables incorporated in the model were the diagnostic/non-diagnostic rate with each respective procedure and the average time taken to reach each procedure. Our analysis was based primarily on the effect of selecting a specific procedure, as the primary diagnostic modality, on the cost and time to diagnosis. Results: When performed as a primary diagnostic procedure in NHGIB patients admitted to the floor, VCE had a diagnostic rate of 68% vs. 45% and 48% for a primary EGD and primary COLO, respectively. The non-diagnostic EGDs [55%] and COLs [52%] underwent a second procedure; the non diagnostic VCEs [32%] did not undergo further procedures. Combining the diagnostic rates for each primary procedure with the cost of performing subsequent procedures [after nondiagnostic primary procedures], demonstrates the use VCE as a primary diagnostic procedure [nZ9] results in a total cost of $12,146 vs. $12,746 and $13,162 for a primary EGD [nZ47] and COLO [nZ33], respectively. In a one way sensitivity analysis, even if the diagnostic rate of VCE reached 100%, requiring a guaranteed second procedure, the cost of performing a primary VCE [$12,445] would still be less than a primary diagnostic EGD [$12,746] or COLO [$13,161]. Combining the diagnostic and non-diagnostic rate of each primary procedure with the time taken to each primary procedure [29 hours to EGD, 38 hours to COLO, 37 hours to VCE], demonstrates the use of VCE as a primary diagnostic procedure in NHGIB patients admitted to the floor would take 74 unit hours to reach a diagnosis compared to 104 and 131 for EGD and COLO, respectively. In a one way sensitivity analysis, the diagnostic rate of EGD and COLO would have to reach 73% and 84%, respectively, to diagnose lesions faster than a primary VCE. Conclusion: Initial use of VCE for the diagnosis of acute NHGIB, may reduce time to diagnosis and management costs.

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Sa1507 Use of the Glasgow-Blatchford Bleeding Score in Bed Assignment for Patients With Suspected UGI Bleeding Drew B. Schembre*1, Janice M. Connolly2, Robson E. Ely1 1 Gastroenterology, Swedish Medical Center, Seattle, WA; 2Hospital Medicine, Swedish Medical Center, Seattle, WA Background: UGI bleeding is a frequent cause for hospitalization. Admission to ICU versus floor bed is usually based on subjective criteria. A more objective tool may help prevent errors in placement that delay needed care or waste resources. The Glasgow-Blatchford bleeding score (GBBS) has been shown to predict hospital mortality and the need for interventions in patients admitted with non-variceal UGI bleeding. Using the GBBS at admission may help stratify patients appropriate for floor care versus intermediate care (IMCU) or ICU. Methods: We reviewed patients admitted with possible UGI bleeding over 32 months to a single tertiary hospital. During the first 16 months, bleeding scores were infrequently calculated. For the last 16 months, scores were calculated by almost all ER physicians. For score !8, floor bed was recommended, 8-12 IMCU and ICU O12. We compared outcomes for patients admitted with and without a GBBS. We also calculated and reviewed GBBS among patients who either died or had admissions O10 days. Results: From October 2011 to June 2014, 456 patients were admitted for presumed UGI bleeding. 281 patients were assigned to beds based on bleeding score and 175 based on physicians’ assessment of risk. Patients stratified by GBBS were more likely to be assigned to IMCU and less likely to go to a floor bed or ICU than those without bleeding scores. Among 68 scored patients placed in floor beds, 7 patients were transferred to a higher level of care and 11 of 140 patients admitted to IMCU were eventually transferred to ICU, compared to 5 of 72 unscored patients admitted to the floor who were later transferred to a higher level of care (pZ0.56) and 13 of 64 IMCU patients transferred to ICU (pZ0.04). Of 31 patients who died or had an admission O10 days, 12 GBBS patients had hospitalizations longer than 10 days and 5 died compared to 8 unscored patients with LOS O10 days and 6 deaths (pZNS). After calculating GBBS for the unscored patients, 27 of 31 (87%) scored 9 or higher and 29 (94%) 7 or higher. No GBBS patient appeared to have died or had a prolonged admission due to a low level of care at admission. One unscored patient admitted to a floor bed, who would have scored 16, died after transfer to ICU and may have benefitted from earlier ICU placement. Conclusion: Use of the GBBS for patients with UGI bleeding may provide more uniform bed assignment and reduce ICU transfers but does not appear to impact LOS, cost or mortality. The great majority of individuals at risk for death or prolonged admission scored O6. The GBBS, along with physician judgment, appears to be a safe and useful tool to direct patient placement. The ideal criteria for bed placement should be determined by larger studies and may vary by facility.

Total Admitted to Floor Bed Admitted to IMCU Admitted to ICU LOS Median Direct Costs Transferred up from Floor Bed Transferred IMCU to ICU Admission O10 Days Death

Patients with GBBS

Patients without GBBS

P value

281 68 (24%) 140 (50%) 73 (26%) 2.75 Days \$5507 7 (11%) 11 (8%) 12 (4%) 5 (2%)

175 72 (41%) 64 (37%) 39 (22%) 2.87 Days \$5481 5 (7%) 13 (20%) 8 (5%) 6 (3%)

!0.01 0.01 0.05 0.82 0.35 0.56 0.04 1.0 0.35

Sa1508 The Role of Ultrathin TransNasal Endoscopy: Meta Analysis Tarek Sawas*, Kia Saeian, Reza Shaker Gastroenterology & Hepatology, Medical College of Wisconsin, Milwaukee, WI Background: Esophagogastroduodenoscopy (EGD) is a common procedure that is usually performed under sedation. The use of sedation improves patients’ tolerance and acceptance. However, It also increases the risk of complications, requires closer monitoring and subsequently increases the cost of the EGD. Ultrathin transnasal endoscopy (T-EGD) was first proposed by Shaker et al. (1993). Since then many randomized controlled trials have evaluated the role of T-EGD in general population and high-risk patients. We report a meta-analysis of prospective controlled trials comparing T-EGD to the conventional regular size sedated and unsedated endoscopy (C-EGD). Method: We searched Pubmed, Embase and Cochrane database for prospective controlled trials that compared T-EGD to regular size C-EGD. Two reviewers selected studies. Quality for each included study was assessed by consort system. No study was eliminated based on quality. Heterogeneity was analyzed by Cochran’s Q statistics. Mantel Haenszel odds ratio (OR) and mean differences (MD) were calculated with fix effect or random effect mode depending on heterogeneity. RevMan 5.2 from Cochrane was used for analysis. Results: 22 prospective controlled trials involving 2921 patients (1626 C-EGD, 1573 T-EGD) were included. Success rate was higher in the C-EGD 98.4% compared to 93.4% in

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