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Su1577 The Impact of Bowel Preparation on Detection of Colorectal Polyps
Abstracts
UPAS, 0:excellent, 1:good, 2:fair, 3:poor, 4:inadequate) Results: 103 patients were enrolled in group A and 107 patients were enrolled in group B. Group B showed better results of bowel preparation than group A in Boston bowel preparation scale and Universal bowel assessment scale. (BBPS, 6.15⫾2.28 vs. 7.43⫾1.86, p⬍0.001, UPAS 1.73⫾0.91 vs. 0.72⫾0.86, p⬍0.001) In group A, there were 5 cases that should be stopped because of poor bowel preparation. Group B showed better results from the point of view of meaningful bowel preparation. (BBPS 5⬃9:0⬃4, UPAS 0⬃2:3⬃4, BBPS 84:19 vs. 100:7, p⫽0.009, UPAS 85:18 vs. 101:6, p⫽0.007) In all ages, cartoon as educational materials had good effect on bowel preparation. Conclusions: Our study demonstrated a good effect of cartoons as a visual educational intervention on the quality of colonoscopy preparation.
Su1577 The Impact of Bowel Preparation on Detection of Colorectal Polyps Susan G. Coe1, Colleen S. Thomas2, Nancy Diehl2, Julia Crook2, Michael B. Wallace1 1 Gastroenterology, Mayo Clinic, Jacksonville, FL; 2Biostatistics, Mayo Clinic, Jacksonville, FL Background: Adequacy of bowel preparation is one of many factors potentially affecting adenoma detection but little objective data exists. Furthermore, description of bowel preparation is often subjective making it difficult to assess it’s impact on adenoma detection in clinical practice. Recently, the Boston Bowel Preparation Score (BBPS) was developed and validated by its authors. The BBPS rates each segment (right, transverse, left) as 0-3 (worst to best). Using this score, we sought to explore the relationship between bowel preparation and adenoma detection. Methods: For all outpatient colonoscopies between 8/2/10 and 10/31/ 10, data were collected prospectively on indication, patient demographics, polyp description and final pathology. Endoscopists were asked to describe bowel preparation using the BBPS. Per patient adenoma detection and the largest adenoma detected by size (ⱕ5mm, 6-9mm, ⱖ10mm) per patient were analyzed by total score and by individual bowel segment score. Total scores were considered in three categories; poor (⬍5), adequate (5-7), and excellent preparations (8-9). Procedures missing a BBPS were excluded. The association between BBPS and polyp detection, and between BBPS and adenoma detection was assessed with the Mann-Whitney test. Among those with adenomas, the association between BBPS and the size of the largest adenoma detected was assessed with Kendall’s tau. Results: Of 1246 colonoscopies between 8/02/10 and 10/31/10, 1180 had total bowel preparation scores (a score present for all 3 segments), 1199 had left segment scores, 1189 had transverse segment scores and 1190 had right segment scores. There was no evidence of association of BBPS with polyp detection (P⫽0.22) or adenoma detection (P⫽0.92). Of the patients with poor, adequate and excellent bowel prep scores the proportion with adenomas detected were 37%, 35%, and 33%, respectively (Table 1). However among patients with adenomas found, adenomas tended to be larger in those with poorer bowel prep (tau⫽ ⫺0.11, p⫽0.004). Similar findings were obtained with separate analyses for each of the three segments regarding polyp and adenoma detection rates, but the effect was most prominent the right colon. (tau⫽ ⫺0.19, p⬍0.001), with lesser evidence of association seen in the transverse colon (tau⫽ ⫺0.09, p⫽0.20) and no association in the left colon (tau⫽0.03, p⫽0.60). Conclusion: Our findings do not support a significant relationship between bowel preparation and overall adenoma detection. We speculate that larger adenomas are detected regardless of marginal bowel preparation. Other influences such as inspection technique likely play more dominant roles in likelihood of adenoma detection. Our study does not have sufficient sample size to assess the impact of bowel preparation on detection of flat and depressed polyps which will be explored in an ongoing study. Table 1. Adenoma detection by total bowel prep score Bowel prep score category Variable Patients with adenomas Patients with polyps
ⱕ 5mm 6-9mm ⱖ 10mm
Purpose: Whole body PET/CT are routinely used to follow response to treatment in many malignancies. Not infrequently, an abnormality is identified in the colon that warrants endoscopic evaluation. Our purpose in this study is to quantify the association of endoscopic findings in patients referred for colonoscopy due to abnormal PET scans based on lesion histology, primary malignancy, and standardized uptake value (SUV). Methods: A retrospective chart review of 72 patients referred for colonoscopy due to colonic uptake on FDG PET/CT was performed. All patients included had a colonoscopy with an adequate prep. The endoscopic findings were compared with PET/CT to determine if there was correlation between the two modalities. The SUV of positive and negative endoscopic evaluation, as well as lesion histology on positive endoscopy was evaluated. The findings were further evaluated based on primary malignancy (i.e. head and neck squamous cell carcinoma, lymphoma, non-small cell lung cancer, primary colon cancer.) Results: Colonoscopy detected a lesion correlating with PET/CT in 34/72 (47%) of cases. Advanced histology, HGD or carcinoma was identified in 9 out of these 34 patients. Of the 38 patients who did not have a lesion correlating with PET/CT uptake, 8 patients had polyps in a different location, though none of these demonstrated advanced histologic features. There was no difference in the mean SUV between those who had a corresponding lesion on endoscopy versus those who did not, 7.7 (95% CI 5-10.4) and 6.1 (95% CI 4.4-7.8), respectively. The patients’ primary malignancy did not predict a higher yield of findings on endoscopic follow up of PET/CT imaging. Conclusions: There is a 47% correlation of colonoscopy and PET/CT findings with at least adenomatous histology and 12.5% correlation of advanced histologic findings with PET/CT. While the correlation for advanced histologic features is not strong, the detection rate is adequate to warrant full colonoscopy in these patients. This particular study suggests that SUV and primary malignancy may be of minimal value in predicting correlation with colonoscopic findings.
Su1579 Clinical Significance of Erosive and/or Small Ulcerative Lesions in the Terminal Ileum During Colonoscopy Yunjung Lee, Sung Hee Jung, Sae Hee Kim, Hyang Ie Lee, Hyeon Woong Yang, Anna Kim, Sang-Woo Cha Eulji University Hospital, Daejeon, Republic of Korea Background/Aims: There are many etiologies and diseases associated with erosions and small ulcers found in the terminal ileum during colonoscopy. However, the significance of these finding is poorly defined. Hence, we want to evaluate the etiology and clinical outcomes in these patients. Methods: We retrospectively reviewed the patients who underwent colonoscopy from January 2006 to December 2009. We enrolled the patients with focal erythema, erosion or small ulcerative lesion (⬍1 cm) in the terminal ileum. After exclusion of the cases with clinical suspicion as inflammatory bowel disease, tuberculosis or acute infectious enteritis, clinical outcomes were evaluated without specific medication in Oct 2010. Results: Of total 23,040 patients who underwent colonoscopy, 592 (2.6%) had abnormal findings of the terminal ileum. After exclusion of patients with specific causes and patients without follow-up colonoscopy, 61 patients (47.6⫾10.2 year, 39 males) were analyzed. The common complaints were mild abdominal discomfort or loose stool (37.1%) and anemia (3.2%). However, a half of them were asymptomatic. During the follow-up, only 9 patients had persisted symptoms. Follow-up colonoscopy was done (mean follow-duration 9.2⫾10.5 months). Abnormal lesions were completely resolved in 28 patients (46.8%). As final diagnosis, 47 patients (75.8%) were diagnosed with nonspecific ileitis, 7 with Behcet disease, 2 with Crohn’s disease, 2 with tuberculosis and 2 with eosinophilic enteritis. Especially, IBD was developed in patients with persistent symptom and unresolved colonoscopic findings (7/9 patients). Conclusions: Erosions and small ulcerative lesions in the terminal ileum are usually regarded as nonspecific finding. However, IBD was found in the patients with persistent presenting symptoms and unchanged conoloscopic findings. So, careful clinical follow-up should be performed in these patients.
Poor (nⴝ105) Adequate (nⴝ 641) Excellent (nⴝ434) 39 (37%) 59 (56%)
225 (35%) 342 (53%)
143 (33%) 210 (48%)
Table 2. Among patients with adenomas, size of largest adenoma detected by total bowel prep score Largest adenoma detected
Su1578 Endoscopic Correlation of Colonic Lesions Detected on PET Sinan Kutty, Reshi Kanuru, Jon P. Walker Ohio State University, Columbus, OH
Bowel prep score category Poor (nⴝ39) Adequate (nⴝ 225) Excellent (nⴝ143) 17 (44%) 7 (18%) 15 (38%)
114 (51%) 45 (20%) 66 (29%)
89 (62%) 25 (17%) 29 (20%)
Su1580 FOBT-Positive-6-Pack Followed by C-Scope Detects Far More CRC’s Than Any Other Combination of Test Shivani J. Kiriluk1,2, Stephen J. Sontag2, Thomas G. Schnell2, Jack Leya2, Harish Bhatia2 1 Loyola University, Maywood, IL; 2Gastroenterology, Edward Hines VA, Hines, IL Introduction: Screening for colorectal cancer (CRC) using a single fecal occult blood test (FOBT) with stool from a single rectal exam (Finger FOBT test) is considered inadequate for cancer detection. Two decades ago it was our policy to ignore the Finger FOBT result and ensure that all patients either proceeded to a FOBT 6-pk or Flexible Sigmoidoscopy (FS). Our initial study reported on the
AB310 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
UPAS, 0:excellent, 1:good, 2:fair, 3:poor, 4:inadequate) Results: 103 patients were enrolled in group A and 107 patients were enrolled in group B. Group B showed better results of bowel preparation than group A in Boston bowel preparation scale and Universal bowel assessment scale. (BBPS, 6.15⫾2.28 vs. 7.43⫾1.86, p⬍0.001, UPAS 1.73⫾0.91 vs. 0.72⫾0.86, p⬍0.001) In group A, there were 5 cases that should be stopped because of poor bowel preparation. Group B showed better results from the point of view of meaningful bowel preparation. (BBPS 5⬃9:0⬃4, UPAS 0⬃2:3⬃4, BBPS 84:19 vs. 100:7, p⫽0.009, UPAS 85:18 vs. 101:6, p⫽0.007) In all ages, cartoon as educational materials had good effect on bowel preparation. Conclusions: Our study demonstrated a good effect of cartoons as a visual educational intervention on the quality of colonoscopy preparation.
Su1577 The Impact of Bowel Preparation on Detection of Colorectal Polyps Susan G. Coe1, Colleen S. Thomas2, Nancy Diehl2, Julia Crook2, Michael B. Wallace1 1 Gastroenterology, Mayo Clinic, Jacksonville, FL; 2Biostatistics, Mayo Clinic, Jacksonville, FL Background: Adequacy of bowel preparation is one of many factors potentially affecting adenoma detection but little objective data exists. Furthermore, description of bowel preparation is often subjective making it difficult to assess it’s impact on adenoma detection in clinical practice. Recently, the Boston Bowel Preparation Score (BBPS) was developed and validated by its authors. The BBPS rates each segment (right, transverse, left) as 0-3 (worst to best). Using this score, we sought to explore the relationship between bowel preparation and adenoma detection. Methods: For all outpatient colonoscopies between 8/2/10 and 10/31/ 10, data were collected prospectively on indication, patient demographics, polyp description and final pathology. Endoscopists were asked to describe bowel preparation using the BBPS. Per patient adenoma detection and the largest adenoma detected by size (ⱕ5mm, 6-9mm, ⱖ10mm) per patient were analyzed by total score and by individual bowel segment score. Total scores were considered in three categories; poor (⬍5), adequate (5-7), and excellent preparations (8-9). Procedures missing a BBPS were excluded. The association between BBPS and polyp detection, and between BBPS and adenoma detection was assessed with the Mann-Whitney test. Among those with adenomas, the association between BBPS and the size of the largest adenoma detected was assessed with Kendall’s tau. Results: Of 1246 colonoscopies between 8/02/10 and 10/31/10, 1180 had total bowel preparation scores (a score present for all 3 segments), 1199 had left segment scores, 1189 had transverse segment scores and 1190 had right segment scores. There was no evidence of association of BBPS with polyp detection (P⫽0.22) or adenoma detection (P⫽0.92). Of the patients with poor, adequate and excellent bowel prep scores the proportion with adenomas detected were 37%, 35%, and 33%, respectively (Table 1). However among patients with adenomas found, adenomas tended to be larger in those with poorer bowel prep (tau⫽ ⫺0.11, p⫽0.004). Similar findings were obtained with separate analyses for each of the three segments regarding polyp and adenoma detection rates, but the effect was most prominent the right colon. (tau⫽ ⫺0.19, p⬍0.001), with lesser evidence of association seen in the transverse colon (tau⫽ ⫺0.09, p⫽0.20) and no association in the left colon (tau⫽0.03, p⫽0.60). Conclusion: Our findings do not support a significant relationship between bowel preparation and overall adenoma detection. We speculate that larger adenomas are detected regardless of marginal bowel preparation. Other influences such as inspection technique likely play more dominant roles in likelihood of adenoma detection. Our study does not have sufficient sample size to assess the impact of bowel preparation on detection of flat and depressed polyps which will be explored in an ongoing study. Table 1. Adenoma detection by total bowel prep score Bowel prep score category Variable Patients with adenomas Patients with polyps
ⱕ 5mm 6-9mm ⱖ 10mm
Purpose: Whole body PET/CT are routinely used to follow response to treatment in many malignancies. Not infrequently, an abnormality is identified in the colon that warrants endoscopic evaluation. Our purpose in this study is to quantify the association of endoscopic findings in patients referred for colonoscopy due to abnormal PET scans based on lesion histology, primary malignancy, and standardized uptake value (SUV). Methods: A retrospective chart review of 72 patients referred for colonoscopy due to colonic uptake on FDG PET/CT was performed. All patients included had a colonoscopy with an adequate prep. The endoscopic findings were compared with PET/CT to determine if there was correlation between the two modalities. The SUV of positive and negative endoscopic evaluation, as well as lesion histology on positive endoscopy was evaluated. The findings were further evaluated based on primary malignancy (i.e. head and neck squamous cell carcinoma, lymphoma, non-small cell lung cancer, primary colon cancer.) Results: Colonoscopy detected a lesion correlating with PET/CT in 34/72 (47%) of cases. Advanced histology, HGD or carcinoma was identified in 9 out of these 34 patients. Of the 38 patients who did not have a lesion correlating with PET/CT uptake, 8 patients had polyps in a different location, though none of these demonstrated advanced histologic features. There was no difference in the mean SUV between those who had a corresponding lesion on endoscopy versus those who did not, 7.7 (95% CI 5-10.4) and 6.1 (95% CI 4.4-7.8), respectively. The patients’ primary malignancy did not predict a higher yield of findings on endoscopic follow up of PET/CT imaging. Conclusions: There is a 47% correlation of colonoscopy and PET/CT findings with at least adenomatous histology and 12.5% correlation of advanced histologic findings with PET/CT. While the correlation for advanced histologic features is not strong, the detection rate is adequate to warrant full colonoscopy in these patients. This particular study suggests that SUV and primary malignancy may be of minimal value in predicting correlation with colonoscopic findings.
Su1579 Clinical Significance of Erosive and/or Small Ulcerative Lesions in the Terminal Ileum During Colonoscopy Yunjung Lee, Sung Hee Jung, Sae Hee Kim, Hyang Ie Lee, Hyeon Woong Yang, Anna Kim, Sang-Woo Cha Eulji University Hospital, Daejeon, Republic of Korea Background/Aims: There are many etiologies and diseases associated with erosions and small ulcers found in the terminal ileum during colonoscopy. However, the significance of these finding is poorly defined. Hence, we want to evaluate the etiology and clinical outcomes in these patients. Methods: We retrospectively reviewed the patients who underwent colonoscopy from January 2006 to December 2009. We enrolled the patients with focal erythema, erosion or small ulcerative lesion (⬍1 cm) in the terminal ileum. After exclusion of the cases with clinical suspicion as inflammatory bowel disease, tuberculosis or acute infectious enteritis, clinical outcomes were evaluated without specific medication in Oct 2010. Results: Of total 23,040 patients who underwent colonoscopy, 592 (2.6%) had abnormal findings of the terminal ileum. After exclusion of patients with specific causes and patients without follow-up colonoscopy, 61 patients (47.6⫾10.2 year, 39 males) were analyzed. The common complaints were mild abdominal discomfort or loose stool (37.1%) and anemia (3.2%). However, a half of them were asymptomatic. During the follow-up, only 9 patients had persisted symptoms. Follow-up colonoscopy was done (mean follow-duration 9.2⫾10.5 months). Abnormal lesions were completely resolved in 28 patients (46.8%). As final diagnosis, 47 patients (75.8%) were diagnosed with nonspecific ileitis, 7 with Behcet disease, 2 with Crohn’s disease, 2 with tuberculosis and 2 with eosinophilic enteritis. Especially, IBD was developed in patients with persistent symptom and unresolved colonoscopic findings (7/9 patients). Conclusions: Erosions and small ulcerative lesions in the terminal ileum are usually regarded as nonspecific finding. However, IBD was found in the patients with persistent presenting symptoms and unchanged conoloscopic findings. So, careful clinical follow-up should be performed in these patients.
Poor (nⴝ105) Adequate (nⴝ 641) Excellent (nⴝ434) 39 (37%) 59 (56%)
225 (35%) 342 (53%)
143 (33%) 210 (48%)
Table 2. Among patients with adenomas, size of largest adenoma detected by total bowel prep score Largest adenoma detected
Su1578 Endoscopic Correlation of Colonic Lesions Detected on PET Sinan Kutty, Reshi Kanuru, Jon P. Walker Ohio State University, Columbus, OH
Bowel prep score category Poor (nⴝ39) Adequate (nⴝ 225) Excellent (nⴝ143) 17 (44%) 7 (18%) 15 (38%)
114 (51%) 45 (20%) 66 (29%)
89 (62%) 25 (17%) 29 (20%)
Su1580 FOBT-Positive-6-Pack Followed by C-Scope Detects Far More CRC’s Than Any Other Combination of Test Shivani J. Kiriluk1,2, Stephen J. Sontag2, Thomas G. Schnell2, Jack Leya2, Harish Bhatia2 1 Loyola University, Maywood, IL; 2Gastroenterology, Edward Hines VA, Hines, IL Introduction: Screening for colorectal cancer (CRC) using a single fecal occult blood test (FOBT) with stool from a single rectal exam (Finger FOBT test) is considered inadequate for cancer detection. Two decades ago it was our policy to ignore the Finger FOBT result and ensure that all patients either proceeded to a FOBT 6-pk or Flexible Sigmoidoscopy (FS). Our initial study reported on the
AB310 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org