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Shortened Duration Video Capsule Endoscopy Leads to Significantly Reduced Rate of Complete Small Bowel Transit
Abstracts
S1439 Peptic Ulcer Bleeding Outcome Is Adversely Affected in Patients with End-Stage Renal Disease Justin Cheung, Andrea Yu, Joseph Labossiere, Richard N. Fedorak Background: Patients with chronic renal failure (CRF) may be at higher risk of bleeding complications as a result of platelet and coagulation dysfunction. To date there have been no studies evaluating peptic ulcer disease (PUD) bleeding outcomes in patients with CRF. Objectives: Using case-controlled methodology we examined PUD bleeding clinical outcomes in patients with and without CRF presenting to two tertiary referral centers. Methods: Medical records of patients presenting with PUD bleeding and CRF between January 2001-2006 were evaluated; Group 1, end-stage renal disease (ESRD), (criteria: chronic hemodialysis or peritoneal dialysis) and Group 2, non-ESRD (age-matched to ESRD, criteria, Cr O100 mmol/L for O 3 months). Results were also compared to an age-matched control population (group 3) with normal renal function (Cr!100 mmol/L). All PUD bleeding patients were treated with proton pump inhibitors on presentation and underwent endoscopy within 24 hours. Results: A total of 111 patients were evaluated (37 ESRD, 37 non-ESRD, 37 normal renal function). The 30 day rebleeding rate was significantly higher in the ESRD group (37.8%) compared to both the non-ESRD CRF group (10.8%, p !0.01) and age-matched control group (10.8%, p ! 0.05). Transfusion requirements post-endoscopy were significantly higher in the ESRD compared to both the non-ESRD and normal control groups (3.1 vs 1.6 vs 1.2 units, respectively, p ! 0.05). The length of hospital stay (57 vs 16 days p ! 0.05) and hospital mortality (16.2% vs 0% p ! 0.05) was significantly higher in the ESRD compared to the normal control group. No differences in the proportion of ulcers with high risk stigmata existed between the each group. Conclusions: ESRD patients with PUD bleeding have higher re-bleeding rates, transfusion requirements, length of stay and mortality rates than patients with normal renal function. In contrast, non-ESRD patients with CRF have outcomes that are similar to patients with normal renal function. Patients with ESRD and PUD bleeding should be assessed and managed as a high risk group.
S1440 The Process of Care for Patients with Upper Gastrointestinal Bleeding David G. Hewett, Bernadette M. Watson, Cindy Gallois, Michael Ward, Barbara A. Leggett Background: Upper gastrointestinal bleeding (UGIB) is a common, clinically significant condition with a high mortality rate. Management requires coordinated multispecialty input from a range of hospital departments and health professionals. Variation in clinical practice from published guidelines may contribute to the high mortality rate in UGIB, and various process improvement interventions have been studied. We aimed to evaluate the process of care for UGIB patients, and identify predictors of time to endoscopy in our single tertiary care facility. Methods: Admissions to a 900 bed teaching hospital during 2005 with symptoms of UGIB were identified from medical record coding and the endoscopic database, and underwent retrospective medical record review. The process of care for UGIB was assessed using established indicators. Regression analysis was used to identify factors predicting time from presentation to performance of upper GI endoscopy in patients with suspected UGIB. Results: 182 admissions with symptoms of new-onset UGIB were identified (95 males, 87 females, median age 67, range 17-97). A blood transfusion was administered in 98 (54%). Upper GI endoscopy was performed in 127 (70%) and was within 24 hours of admission in 73 (40%). Rebleeding occurred in 16 (9%), surgery was performed for bleeding in 5 (3%), and 18 (10%) died in hospital. The most common endoscopic diagnosis was peptic ulcer (n Z 43, 34%). An analysis of time to endoscopy (TTE) was performed after excluding admissions in which TTE was O1 week as they may represent a different population (n Z 5). Correlational analysis showed no significant association between TTE and the clinical variables of systolic blood pressure, pre-endoscopy Rockall score1 or ASA status. Multiple regression analysis indicated that the significant predictors of TTE (p ! 0.05) in the final regression model were performance of endoscopy afterhours, administration of intravenous PPI, blood transfusion, and admission to the gastroenterology service rather than internal medicine (F Z 4.97, p ! .001, adj R2 Z 0.23). Conclusions: Deficits in the quality of care for UGIB admissions as assessed using process indicators were evident, specifically time to endoscopy. These data support previous research2 that process of care and logistical factors are important predictors of time to endoscopy in UGIB. In our tertiary centre, process issues are stronger predictors than clinical variables. Further research is required to establish whether risk stratification in this setting using published scoring systems and a clinical pathway may improve performance on quality indicators. 1 Rockall et al Gut 1996; 2 da Silveira et al GIE 2006.
AB176 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
S1441 Direct Percutaneous Endoscopic Jejunostomy (DPEJ) in Patients with Prior Abdominal Surgery Robert F. Wong, Scott H. Mackenzie, Kristen Thomas, Kristen Hilden, John C. Fang Background: DPEJ is increasingly utilized as a method for obtaining jejunal enteral access. Prior abdominal surgery may adversely affect procedural success and adverse events (AEs) secondary to adhesions. Prior esophagectomy or gastric surgery may also affect procedure outcomes secondary to altered anatomy. Aim: Evaluate the success rate and AEs associated with DPEJ placement in patients with prior abdominal surgery. Methods: Retrospective database analysis identified 98 DPEJ placements which had full data available for analysis at the University of Utah between February 2000 and November 2006. Patients were identified who had prior abdominal and/or pelvic surgery, excluding tubal ligation. These were further subclassified into patients who had prior esophageal or gastric surgery (GE surgery), primarily esophagectomy, Bilroth I/II or gastric bypass. The primary endpoint was DPEJ placement success in patients with prior abdominal surgery compared to those without abdominal surgery (controls). An additional comparison was made between patients with prior GE surgery compared to controls. Secondary endpoints included procedure time and AEs. Results: 98 DPEJs were placed in 92 patients (60 F, mean age 45). Overall, 81 procedures (83%) were successful and 17 (17%) failed. Fifty-six patients had prior abdominal surgery, including 16 who had GE surgery. Procedure success rates were as follows: 83% (controls), 82% (abdominal surgery) and 76% (GE surgery). Mean procedure time was 43 min (controls), 47 min (abdominal surgery) and 44 min (GE surgery). AEs occurred in 33% of controls, 44% with abdominal surgery and 29% of those with GE surgery. There were no significant differences in procedure success rates, times or AEs between any of the surgical groups and controls (p O 0.05). There was also no differences in these outcomes if patients were analyzed based on BMI (greater than or less than 25). Conclusions: DPEJ placement in patients with prior abdominal surgery, including esophagectomy or gastric surgery, appears to be similarly successful and safe compared to patients without abdominal surgery. Previous abdominal surgery should not be a deterrent for DPEJ placement.
S1442 Shortened Duration Video Capsule Endoscopy Leads to Significantly Reduced Rate of Complete Small Bowel Transit Venessa Pattullo, Ross Hansen, Timothy R. Heap Introduction and Aims: Although the development of the video capsule endoscopy technology has progressed rapidly, there is currently no consensus on the optimum duration of the capsule endoscopy examination. Differing generations of the video capsule endoscope have had differing battery lives, and record images of small bowel transit over differing lengths of time (between 6 and 10 hours). The rate of incomplete small bowel transit (defined by failure of the capsule to enter the caecum) has been reported in the literature to be as high as 35% and this may have clinical consequences. The aim of this study was to determine the effect of shorter study periods on the rate of complete small bowel transit. Methods: Ninety-five consecutive capsule endoscopies performed in patients being investigated for occult or overt gastrointestinal bleeding were reviewed retrospectively. Capsule endoscopies were performed using the Given Rapid 3 system which limited the capsule endoscopy imaging time to 8.5 hours. Prokinetic agents were not used. Cases in which the capsule entered the caecum and hence complete small bowel transit was achieved were noted, and the total transit time (gastric transit time plus small bowel transit time) recorded. The rate of complete small bowel transit was stratified by total transit time. McNemar’s test was utilised to determine statistical differences between rates of complete small bowel transit achieved at varying timepoints. Results: The rate of complete small bowel transit at 8.5 hours was 87.4%. There was no difference between the success rates between the 7.5 and 8.0 hour time points. There was a significantly lower rate of complete small bowel transit at a cut off of 6 hours compared with 8.0 hours (p ! 0.001) and 7.0 hours compared with 8.0 hours (p ! 0.05). There was a small increase in success rate between the 8.0 and 8.5 hour time points, but this was not statistically significant (p Z 0.13). Conclusions: Capsule endoscopy examinations of a shorter duration have a statistically significant reduced rate of complete small bowel transit. The stratification of complete small bowel transit rate should be repeated in larger populations and the clinical consequences of incomplete transit determined in order to reach consensus on the optimum duration of video capsule endoscopy. Rate of complete small bowel transit (success rate) at varying timepoints 6.0 hrs
6.5 hrs
7.0 hrs
7.5 hrs
Success rate (%) 67% 70% 75% 83% Successful cases (n) 64) 66 71# 79 )p ! 0.001 vs 8 hrs; #p ! 0.05 vs 8 hrs; $p Z 0.13 vs 8.5 hrs
8.0 hrs
8.5 hrs
83% 79$
87% 83
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S1439 Peptic Ulcer Bleeding Outcome Is Adversely Affected in Patients with End-Stage Renal Disease Justin Cheung, Andrea Yu, Joseph Labossiere, Richard N. Fedorak Background: Patients with chronic renal failure (CRF) may be at higher risk of bleeding complications as a result of platelet and coagulation dysfunction. To date there have been no studies evaluating peptic ulcer disease (PUD) bleeding outcomes in patients with CRF. Objectives: Using case-controlled methodology we examined PUD bleeding clinical outcomes in patients with and without CRF presenting to two tertiary referral centers. Methods: Medical records of patients presenting with PUD bleeding and CRF between January 2001-2006 were evaluated; Group 1, end-stage renal disease (ESRD), (criteria: chronic hemodialysis or peritoneal dialysis) and Group 2, non-ESRD (age-matched to ESRD, criteria, Cr O100 mmol/L for O 3 months). Results were also compared to an age-matched control population (group 3) with normal renal function (Cr!100 mmol/L). All PUD bleeding patients were treated with proton pump inhibitors on presentation and underwent endoscopy within 24 hours. Results: A total of 111 patients were evaluated (37 ESRD, 37 non-ESRD, 37 normal renal function). The 30 day rebleeding rate was significantly higher in the ESRD group (37.8%) compared to both the non-ESRD CRF group (10.8%, p !0.01) and age-matched control group (10.8%, p ! 0.05). Transfusion requirements post-endoscopy were significantly higher in the ESRD compared to both the non-ESRD and normal control groups (3.1 vs 1.6 vs 1.2 units, respectively, p ! 0.05). The length of hospital stay (57 vs 16 days p ! 0.05) and hospital mortality (16.2% vs 0% p ! 0.05) was significantly higher in the ESRD compared to the normal control group. No differences in the proportion of ulcers with high risk stigmata existed between the each group. Conclusions: ESRD patients with PUD bleeding have higher re-bleeding rates, transfusion requirements, length of stay and mortality rates than patients with normal renal function. In contrast, non-ESRD patients with CRF have outcomes that are similar to patients with normal renal function. Patients with ESRD and PUD bleeding should be assessed and managed as a high risk group.
S1440 The Process of Care for Patients with Upper Gastrointestinal Bleeding David G. Hewett, Bernadette M. Watson, Cindy Gallois, Michael Ward, Barbara A. Leggett Background: Upper gastrointestinal bleeding (UGIB) is a common, clinically significant condition with a high mortality rate. Management requires coordinated multispecialty input from a range of hospital departments and health professionals. Variation in clinical practice from published guidelines may contribute to the high mortality rate in UGIB, and various process improvement interventions have been studied. We aimed to evaluate the process of care for UGIB patients, and identify predictors of time to endoscopy in our single tertiary care facility. Methods: Admissions to a 900 bed teaching hospital during 2005 with symptoms of UGIB were identified from medical record coding and the endoscopic database, and underwent retrospective medical record review. The process of care for UGIB was assessed using established indicators. Regression analysis was used to identify factors predicting time from presentation to performance of upper GI endoscopy in patients with suspected UGIB. Results: 182 admissions with symptoms of new-onset UGIB were identified (95 males, 87 females, median age 67, range 17-97). A blood transfusion was administered in 98 (54%). Upper GI endoscopy was performed in 127 (70%) and was within 24 hours of admission in 73 (40%). Rebleeding occurred in 16 (9%), surgery was performed for bleeding in 5 (3%), and 18 (10%) died in hospital. The most common endoscopic diagnosis was peptic ulcer (n Z 43, 34%). An analysis of time to endoscopy (TTE) was performed after excluding admissions in which TTE was O1 week as they may represent a different population (n Z 5). Correlational analysis showed no significant association between TTE and the clinical variables of systolic blood pressure, pre-endoscopy Rockall score1 or ASA status. Multiple regression analysis indicated that the significant predictors of TTE (p ! 0.05) in the final regression model were performance of endoscopy afterhours, administration of intravenous PPI, blood transfusion, and admission to the gastroenterology service rather than internal medicine (F Z 4.97, p ! .001, adj R2 Z 0.23). Conclusions: Deficits in the quality of care for UGIB admissions as assessed using process indicators were evident, specifically time to endoscopy. These data support previous research2 that process of care and logistical factors are important predictors of time to endoscopy in UGIB. In our tertiary centre, process issues are stronger predictors than clinical variables. Further research is required to establish whether risk stratification in this setting using published scoring systems and a clinical pathway may improve performance on quality indicators. 1 Rockall et al Gut 1996; 2 da Silveira et al GIE 2006.
AB176 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
S1441 Direct Percutaneous Endoscopic Jejunostomy (DPEJ) in Patients with Prior Abdominal Surgery Robert F. Wong, Scott H. Mackenzie, Kristen Thomas, Kristen Hilden, John C. Fang Background: DPEJ is increasingly utilized as a method for obtaining jejunal enteral access. Prior abdominal surgery may adversely affect procedural success and adverse events (AEs) secondary to adhesions. Prior esophagectomy or gastric surgery may also affect procedure outcomes secondary to altered anatomy. Aim: Evaluate the success rate and AEs associated with DPEJ placement in patients with prior abdominal surgery. Methods: Retrospective database analysis identified 98 DPEJ placements which had full data available for analysis at the University of Utah between February 2000 and November 2006. Patients were identified who had prior abdominal and/or pelvic surgery, excluding tubal ligation. These were further subclassified into patients who had prior esophageal or gastric surgery (GE surgery), primarily esophagectomy, Bilroth I/II or gastric bypass. The primary endpoint was DPEJ placement success in patients with prior abdominal surgery compared to those without abdominal surgery (controls). An additional comparison was made between patients with prior GE surgery compared to controls. Secondary endpoints included procedure time and AEs. Results: 98 DPEJs were placed in 92 patients (60 F, mean age 45). Overall, 81 procedures (83%) were successful and 17 (17%) failed. Fifty-six patients had prior abdominal surgery, including 16 who had GE surgery. Procedure success rates were as follows: 83% (controls), 82% (abdominal surgery) and 76% (GE surgery). Mean procedure time was 43 min (controls), 47 min (abdominal surgery) and 44 min (GE surgery). AEs occurred in 33% of controls, 44% with abdominal surgery and 29% of those with GE surgery. There were no significant differences in procedure success rates, times or AEs between any of the surgical groups and controls (p O 0.05). There was also no differences in these outcomes if patients were analyzed based on BMI (greater than or less than 25). Conclusions: DPEJ placement in patients with prior abdominal surgery, including esophagectomy or gastric surgery, appears to be similarly successful and safe compared to patients without abdominal surgery. Previous abdominal surgery should not be a deterrent for DPEJ placement.
S1442 Shortened Duration Video Capsule Endoscopy Leads to Significantly Reduced Rate of Complete Small Bowel Transit Venessa Pattullo, Ross Hansen, Timothy R. Heap Introduction and Aims: Although the development of the video capsule endoscopy technology has progressed rapidly, there is currently no consensus on the optimum duration of the capsule endoscopy examination. Differing generations of the video capsule endoscope have had differing battery lives, and record images of small bowel transit over differing lengths of time (between 6 and 10 hours). The rate of incomplete small bowel transit (defined by failure of the capsule to enter the caecum) has been reported in the literature to be as high as 35% and this may have clinical consequences. The aim of this study was to determine the effect of shorter study periods on the rate of complete small bowel transit. Methods: Ninety-five consecutive capsule endoscopies performed in patients being investigated for occult or overt gastrointestinal bleeding were reviewed retrospectively. Capsule endoscopies were performed using the Given Rapid 3 system which limited the capsule endoscopy imaging time to 8.5 hours. Prokinetic agents were not used. Cases in which the capsule entered the caecum and hence complete small bowel transit was achieved were noted, and the total transit time (gastric transit time plus small bowel transit time) recorded. The rate of complete small bowel transit was stratified by total transit time. McNemar’s test was utilised to determine statistical differences between rates of complete small bowel transit achieved at varying timepoints. Results: The rate of complete small bowel transit at 8.5 hours was 87.4%. There was no difference between the success rates between the 7.5 and 8.0 hour time points. There was a significantly lower rate of complete small bowel transit at a cut off of 6 hours compared with 8.0 hours (p ! 0.001) and 7.0 hours compared with 8.0 hours (p ! 0.05). There was a small increase in success rate between the 8.0 and 8.5 hour time points, but this was not statistically significant (p Z 0.13). Conclusions: Capsule endoscopy examinations of a shorter duration have a statistically significant reduced rate of complete small bowel transit. The stratification of complete small bowel transit rate should be repeated in larger populations and the clinical consequences of incomplete transit determined in order to reach consensus on the optimum duration of video capsule endoscopy. Rate of complete small bowel transit (success rate) at varying timepoints 6.0 hrs
6.5 hrs
7.0 hrs
7.5 hrs
Success rate (%) 67% 70% 75% 83% Successful cases (n) 64) 66 71# 79 )p ! 0.001 vs 8 hrs; #p ! 0.05 vs 8 hrs; $p Z 0.13 vs 8.5 hrs
8.0 hrs
8.5 hrs
83% 79$
87% 83
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