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Sa1669 Endoscopist Characteristics and Quality Indicators in Pediatric Colonoscopy
Abstracts Table 1. Patients submitted to primary prophylaxis with EBL due PH.
Patient 1 2 3 4 5 6 7 8 9
Diagnostic ALPHA 1 DEF BA PFIC PVT BA BA PVT BA PVT
Age at 1st endoscopy
Follow up (years)
Total of exams
N of exams with EBL
N of EBL
Final status
4
3.36
4
1
2
Worse
3.2 2.06 3.45 1.42 2.38 2.11 3.42 3.62
7.81 9.92 3.90 0.21 0.0 4.27 8.55 5.68
10 13 9 5 1 8 11 11
5 5 7 5 1 5 7 7
9 7 11 7 3 12 15 11
Erradicated Erradicated Unchanged Erradicated LT Erradicated Improved Improved
ALPHA 1 DEF - Alpha 1 Antitrypsin deficiency, PFIC - Progressive Familial Intrahepatic Cholesthasis, PVT - Portal Vein Thrombosis. BA - Billiary Atresia, LT - Liver Transplant
Figure 1. Image of the developed device with smaller diameter for EBL in small children (left), in comparison with a regular device (right), in lateral and font view
Sa1667 The Safety and Effectiveness of Carbon Dioxide Insufflation During Colonoscopy in Sedated Pediatric Patients With Inflammatory Bowel Disease Yoshiko Nakayama*, Naoki Abe, Mai Kusakari, Sawako Kato, Nao Hidaka Shinshu University School of Medicine, Matsumoto, Japan Introduction: Several studies in adults have shown that insufflation of carbon dioxide(CO2) instead of air can minimize abdominal pain after colonoscopy. However, little is known about the safety and effectiveness of CO2 insufflation in sedated pediatric patients with inflammatory bowel disease(IBD). The objective of our study was to investigate whether CO2 insufflation can reduce abdominal pain after colonoscopy and leads to CO2 retention. Methods: A total of consecutive 54 patients with Crohn’s disease or ulcerative colitis were undergo total colonoscopy with insufflation of air(nZ18) or CO2(nZ36). The procedure time, abdominal circumference before and after colonoscopy, end-tidal carbon dioxide(ETCO2) were recorded. We also examine retrospectively whether additional sedative drugs needed during colonoscopy because of pain or body movement, the abdominal pain within 24 hours after colonoscopy, and whether the underlying disease got worse within 1 week. Results: In the CO2 group, the abdominal circumference increased only an average of 0.9cm. The maximum EtCO2 procedure was 40.8% in the CO2 group and 37.2% in the air group. There were no patient who had abdominal pain within 24 hours after colonoscopy in the CO2 group, whereas two patients in the air group. Only in the air group, one patient got worse of diarrhea and blood feces after colonoscopy. Conclusions: This study indicates that CO2 insufflation could reduce abdominal pain after colonoscopy and use safely in sedated pediatric patients.
Sa1668 Utility of Routine Colonic Biopsies in Pediatric Patients Undergoing Colonoscopic Polypectomy for Juvenile Polyps Michael A. Malandra*, Sunpreet Kaur, Ashish Chogle Pediatric Gastroenterology, Ann & Robert H Lurie Children’s Hospital of Chicago, Chicago, IL Introduction: Benign colonic juvenile polyps are a common finding in young children. These polyps are removed via colonoscopy and most juvenile polyps have no neoplastic potential. The practice of obtaining colonic mucosal biopsies during polypectomies is not evidence based but is commonly done by pediatric gastroenterologists. We aim to determine the benefit of obtaining routine colonic biopsies during polypectomies for benign juvenile polyps. Methods: We performed a
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retrospective chart review identifying all patients aged 1 to 18 years who underwent a complete colonoscopy and polypectomy for suspected colo-rectal polyps from January 1st, 2004 to July 1st, 2014 at Ann & Robert H. Lurie Children’s Hospital of Chicago. Demographic information, indication for procedure, number of polyps, gross and histologic findings, and any management changes that resulted from endoscopic findings were recorded. A colonoscopy was considered to be complete if it included examination of the cecum or terminal ileum. Exclusion criteria included known history of polyposis syndrome, more than 5 polyps on colonoscopy, history or endoscopic findings suggestive of inflammatory bowel disease, and incomplete procedure documentation. Results: A total of 141 patients underwent colonoscopy with polypectomy of which 72 patients were included. 63% were male, the mean age was 6.5 years (range: 1-17 years), and all had hematochezia at presentation. There were gross findings other than colorectal polyps in 7 patients (10%) and these included lymphonodular hyperplasia, small ulcer in the sigmoid colon, and small erythematous cecal patch. 68 patients (94%) had juvenile inflammatory polyps on histologic exam. Routine colonic biopsies were performed in 55 patients (76%). In 8 of these patients (15%), histologic abnormalities such as mild focal active colitis and mild chronic colitis were seen. In all these cases, there was no change in management based on histologic findings. Conclusion: In children undergoing colonoscopic polypectomy for benign juvenile polyps, routine colonic biopsies may not be performed in the absence of mucosal abnormalities. The overuse of pathology services and increased procedural time, risk and cost can be avoided.
Sa1669 Endoscopist Characteristics and Quality Indicators in Pediatric Colonoscopy Kalpesh H. Thakkar*1, Jennifer L. Holub2, Mark A. Gilger1, Mitchell Shub3, Mark E. Mcomber3, Victor M. Tsou4, Douglas S. Fishman1 1 GI, Baylor College of Medicine, Houston, TX; 2of Gastroenterology, Oregon Health & Science University, Portland, OR; 3Department of Child Health, Phoenix Children’s Hospital, Phoenix, AZ; 4Children’s Hospital of The King’s Daughters, Norfolk, VA Background: Current data suggest significant variations in the practice of pediatric endoscopy are prevalent. We aimed to determine if specific endoscopist characteristics (e.g. sex, colonoscopy volume, year graduated from medical school) were associated with quality indicators in children undergoing colonoscopy. Methods: We conducted prospective data collection using a standard computerized report generator and central registry (Pediatric Endoscopy Database System-Clinical Outcomes Research Initiative; PEDS-CORI) to examine key quality indicators from 14 pediatric centers between Jan 2000 and Dec 2011. Specific endpoints, including quality of bowel prep, duration of procedure, ileal intubation rate, documentation of ASA class, and procedure time were compared among endoscopists with more than 10 colonoscopy procedures during the study period. Results: We analyzed data from 120 endoscopists and 21, 807 colonoscopy procedures performed in patients with mean age of 11.9 (SD 4.8). Endoscopists who graduated after the year 2000 had a higher ileal intubation rate than endoscopists who graduated before 1990 (86% vs 66%, p ! 0.01). Mean duration of colonoscopy was shorter in endoscopists with at least 200 colonoscopies than those with less than 50 (30.2 min vs. 40.5 min, p ! 0.01). There were no significant associations between specific endoscopist characteristics and unplanned events, bowel prep documentation, or adequate bowel prep. Conclusions: Analysis of endoscopist characteristics showed that endoscopists with higher colonoscopy volume tend to perform the procedure more rapidly. Additionally, more recently trained endoscopists (who graduated after the year 2000) achieve a higher rate of ileal intubation.
Sa1670 Clostridium difficile Under the Microscope: RATES of C Diff Toxin Detection and Clinically-Significant Colitis Found At Time of Pediatric Colonoscopy Randolph M. Mcconnie, Arthur Kastl* Pediatrics, Rush University Medical Center, Chicago, Il Background: The frequency of Clostridium difficile (CD) infection has increased over the past decade, with peak incidence in 1-4-year olds. Since positive tests for CD toxin (CDT) may be misleading in children, it is important to limit testing and treatment to cases with meaningful disease. Children younger than 1-2 years old rarely have severe disease, and the probability of clinically meaningful disease is low in children 2-5 years old. However, the prevalence of pathogens found at the time of endoscopy, and their correlation with meaningful disease, is largely unknown. Methods: A retrospective chart review of colonoscopies of 392 children between 2006-2013 was performed. Sigmoidoscopy and ileoscopy were excluded. All colonoscopes used were sterilized following industry accepted and validated techniques. Stool was aspirated thru the colonoscope at the time of the study, collected in a sterile lukens trap, and sent for cultures including CDT, stool culture for enteric pathogens, ova/parasite preparation, and Giardia/Cryptosporidium antigen. Endoscopy and histology reports were reviewed for evidence of inflammation. For patients
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB301
Patient 1 2 3 4 5 6 7 8 9
Diagnostic ALPHA 1 DEF BA PFIC PVT BA BA PVT BA PVT
Age at 1st endoscopy
Follow up (years)
Total of exams
N of exams with EBL
N of EBL
Final status
4
3.36
4
1
2
Worse
3.2 2.06 3.45 1.42 2.38 2.11 3.42 3.62
7.81 9.92 3.90 0.21 0.0 4.27 8.55 5.68
10 13 9 5 1 8 11 11
5 5 7 5 1 5 7 7
9 7 11 7 3 12 15 11
Erradicated Erradicated Unchanged Erradicated LT Erradicated Improved Improved
ALPHA 1 DEF - Alpha 1 Antitrypsin deficiency, PFIC - Progressive Familial Intrahepatic Cholesthasis, PVT - Portal Vein Thrombosis. BA - Billiary Atresia, LT - Liver Transplant
Figure 1. Image of the developed device with smaller diameter for EBL in small children (left), in comparison with a regular device (right), in lateral and font view
Sa1667 The Safety and Effectiveness of Carbon Dioxide Insufflation During Colonoscopy in Sedated Pediatric Patients With Inflammatory Bowel Disease Yoshiko Nakayama*, Naoki Abe, Mai Kusakari, Sawako Kato, Nao Hidaka Shinshu University School of Medicine, Matsumoto, Japan Introduction: Several studies in adults have shown that insufflation of carbon dioxide(CO2) instead of air can minimize abdominal pain after colonoscopy. However, little is known about the safety and effectiveness of CO2 insufflation in sedated pediatric patients with inflammatory bowel disease(IBD). The objective of our study was to investigate whether CO2 insufflation can reduce abdominal pain after colonoscopy and leads to CO2 retention. Methods: A total of consecutive 54 patients with Crohn’s disease or ulcerative colitis were undergo total colonoscopy with insufflation of air(nZ18) or CO2(nZ36). The procedure time, abdominal circumference before and after colonoscopy, end-tidal carbon dioxide(ETCO2) were recorded. We also examine retrospectively whether additional sedative drugs needed during colonoscopy because of pain or body movement, the abdominal pain within 24 hours after colonoscopy, and whether the underlying disease got worse within 1 week. Results: In the CO2 group, the abdominal circumference increased only an average of 0.9cm. The maximum EtCO2 procedure was 40.8% in the CO2 group and 37.2% in the air group. There were no patient who had abdominal pain within 24 hours after colonoscopy in the CO2 group, whereas two patients in the air group. Only in the air group, one patient got worse of diarrhea and blood feces after colonoscopy. Conclusions: This study indicates that CO2 insufflation could reduce abdominal pain after colonoscopy and use safely in sedated pediatric patients.
Sa1668 Utility of Routine Colonic Biopsies in Pediatric Patients Undergoing Colonoscopic Polypectomy for Juvenile Polyps Michael A. Malandra*, Sunpreet Kaur, Ashish Chogle Pediatric Gastroenterology, Ann & Robert H Lurie Children’s Hospital of Chicago, Chicago, IL Introduction: Benign colonic juvenile polyps are a common finding in young children. These polyps are removed via colonoscopy and most juvenile polyps have no neoplastic potential. The practice of obtaining colonic mucosal biopsies during polypectomies is not evidence based but is commonly done by pediatric gastroenterologists. We aim to determine the benefit of obtaining routine colonic biopsies during polypectomies for benign juvenile polyps. Methods: We performed a
www.giejournal.org
retrospective chart review identifying all patients aged 1 to 18 years who underwent a complete colonoscopy and polypectomy for suspected colo-rectal polyps from January 1st, 2004 to July 1st, 2014 at Ann & Robert H. Lurie Children’s Hospital of Chicago. Demographic information, indication for procedure, number of polyps, gross and histologic findings, and any management changes that resulted from endoscopic findings were recorded. A colonoscopy was considered to be complete if it included examination of the cecum or terminal ileum. Exclusion criteria included known history of polyposis syndrome, more than 5 polyps on colonoscopy, history or endoscopic findings suggestive of inflammatory bowel disease, and incomplete procedure documentation. Results: A total of 141 patients underwent colonoscopy with polypectomy of which 72 patients were included. 63% were male, the mean age was 6.5 years (range: 1-17 years), and all had hematochezia at presentation. There were gross findings other than colorectal polyps in 7 patients (10%) and these included lymphonodular hyperplasia, small ulcer in the sigmoid colon, and small erythematous cecal patch. 68 patients (94%) had juvenile inflammatory polyps on histologic exam. Routine colonic biopsies were performed in 55 patients (76%). In 8 of these patients (15%), histologic abnormalities such as mild focal active colitis and mild chronic colitis were seen. In all these cases, there was no change in management based on histologic findings. Conclusion: In children undergoing colonoscopic polypectomy for benign juvenile polyps, routine colonic biopsies may not be performed in the absence of mucosal abnormalities. The overuse of pathology services and increased procedural time, risk and cost can be avoided.
Sa1669 Endoscopist Characteristics and Quality Indicators in Pediatric Colonoscopy Kalpesh H. Thakkar*1, Jennifer L. Holub2, Mark A. Gilger1, Mitchell Shub3, Mark E. Mcomber3, Victor M. Tsou4, Douglas S. Fishman1 1 GI, Baylor College of Medicine, Houston, TX; 2of Gastroenterology, Oregon Health & Science University, Portland, OR; 3Department of Child Health, Phoenix Children’s Hospital, Phoenix, AZ; 4Children’s Hospital of The King’s Daughters, Norfolk, VA Background: Current data suggest significant variations in the practice of pediatric endoscopy are prevalent. We aimed to determine if specific endoscopist characteristics (e.g. sex, colonoscopy volume, year graduated from medical school) were associated with quality indicators in children undergoing colonoscopy. Methods: We conducted prospective data collection using a standard computerized report generator and central registry (Pediatric Endoscopy Database System-Clinical Outcomes Research Initiative; PEDS-CORI) to examine key quality indicators from 14 pediatric centers between Jan 2000 and Dec 2011. Specific endpoints, including quality of bowel prep, duration of procedure, ileal intubation rate, documentation of ASA class, and procedure time were compared among endoscopists with more than 10 colonoscopy procedures during the study period. Results: We analyzed data from 120 endoscopists and 21, 807 colonoscopy procedures performed in patients with mean age of 11.9 (SD 4.8). Endoscopists who graduated after the year 2000 had a higher ileal intubation rate than endoscopists who graduated before 1990 (86% vs 66%, p ! 0.01). Mean duration of colonoscopy was shorter in endoscopists with at least 200 colonoscopies than those with less than 50 (30.2 min vs. 40.5 min, p ! 0.01). There were no significant associations between specific endoscopist characteristics and unplanned events, bowel prep documentation, or adequate bowel prep. Conclusions: Analysis of endoscopist characteristics showed that endoscopists with higher colonoscopy volume tend to perform the procedure more rapidly. Additionally, more recently trained endoscopists (who graduated after the year 2000) achieve a higher rate of ileal intubation.
Sa1670 Clostridium difficile Under the Microscope: RATES of C Diff Toxin Detection and Clinically-Significant Colitis Found At Time of Pediatric Colonoscopy Randolph M. Mcconnie, Arthur Kastl* Pediatrics, Rush University Medical Center, Chicago, Il Background: The frequency of Clostridium difficile (CD) infection has increased over the past decade, with peak incidence in 1-4-year olds. Since positive tests for CD toxin (CDT) may be misleading in children, it is important to limit testing and treatment to cases with meaningful disease. Children younger than 1-2 years old rarely have severe disease, and the probability of clinically meaningful disease is low in children 2-5 years old. However, the prevalence of pathogens found at the time of endoscopy, and their correlation with meaningful disease, is largely unknown. Methods: A retrospective chart review of colonoscopies of 392 children between 2006-2013 was performed. Sigmoidoscopy and ileoscopy were excluded. All colonoscopes used were sterilized following industry accepted and validated techniques. Stool was aspirated thru the colonoscope at the time of the study, collected in a sterile lukens trap, and sent for cultures including CDT, stool culture for enteric pathogens, ova/parasite preparation, and Giardia/Cryptosporidium antigen. Endoscopy and histology reports were reviewed for evidence of inflammation. For patients
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB301