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Tu1079 Adherence to Surveillance Guidelines in Patients With Barrett's Esophagus (BE): Analysis From a Large Multicenter Cohort Study
Tu1077
assess for independent predictors of over-surveillance. Methods: This is a multicenter outcomes project (5 centers) of a large cohort of BE patients. BE was defined by columnar metaplasia in the tubular esophagus on endoscopy and intestinal metaplasia on biopsy. Demographics, medication use, family history, and endoscopy results were recorded. Neoplasia was graded as low-grade dysplasia (LGD), high-grade dysplasia (HGD) and EAC. Adherence was defined as a repeat endoscopy within 1-3 years of diagnosis for NDBE and within 6-12 months for LGD. Over-surveillance was defined as undergoing endoscopic surveillance before the above defined surveillance intervals. Fisher's exact test and Mann-Whitney U test were used to compare categorical and continuous variables, respectively. Factors significant on univariate analysis were examined using a stepwise, multivariate logistic regression model to examine predictors for over-surveillance. Results: 3635 patients were included in the analysis [87.8% males, 92.8% Caucasians, mean BMI 28.4 (SD 6.1), mean age 60.9 (SD 12.3), and mean BE length 3.5 cm (SD 3.3)]. On the initial diagnostic endoscopy, 2237 patients were found to have BE without dysplasia (NDBE) and 378 patients were found to have LGD. Of the NDBE patients, 1593 (71.2%) underwent repeat endoscopic surveillance at any point; 22.6% of patients underwent surveillance EGD before the intervals described above. Patients who had LGD were more likely to undergo surveillance endoscopy prior to the recommended period (48% within 6 months, 23% within 6 to 12 months) (Table 1). Comparing patients who were over-surveyed vs. others on univariate analysis, statistically significant differences were seen in age, gender, presence of visible lesion, index histology (NDBE or LGD), and BE length (all p<0.05). No differences in adherence rates were seen based on race, age, or PPI use. On multivariate logistic regression model, patients with LGD on endoscopy were more likely to be over-surveyed [OR = 2.9 (2.2 - 3.7), p<0.01). Other independent predictors included older age, male gender, and the presence of a visible lesion on index endoscopy (Table 2). Conclusions: Despite published guidelines for BE surveillance, overall adherence rates were low even at centers with expertise in BE. Approximately half of the patients with LGD were likely to be over-surveyed. Given the low reproducibility of LGD diagnosis, this potentially represents a significant burden to the health care system. Future studies should evaluate patient and physician factors affecting adherence to BE surveillance guidelines.
AGA Abstracts
Abdominal Pain and Factors Influencing Prescription Patterns of Proton Pump Inhibitors in Emergency Room Visits Arunkumar Muthusamy, Palaniappan Manickam Background: Abdominal pain is a common reason for ER visits. Acid suppression therapy (AST) using proton pump inhibitors and H2-blockers is commonly prescribed in ER for abdominal pain. As inappropriate use of AST can contribute to drug interactions, pneumonia, and increased health care expenditure, we wanted to look for factors which influence prescribing patterns of AST in ER. Objectives: To evaluate if age, gender differences, severity of abdominal pain and length of ER stay influence prescription of acid suppression therapy (AST) in patients presenting to ER with abdominal pain. Methods: We analyzed the limited access dataset of National Hospital Ambulatory Medical Care Survey (2006 to 2009) for ER visits. We included all patients above 15 years of age presenting to ER with upper abdominal pain. We calculated and compared AST prescription rates based on age, gender, severity of pain and length of ER visit. Statistical analysis was done using multivariate logistic regression. Results: There were a total of 1, 12,810 patient visits. Of these, 11,496 visits were for abdominal pain consisting of 70% women and 30% men. Men were 36% more likely to receive AST compared to women (OR 1.35 95% CI 1.18 to 1.57). Patients in age group 45-64 years were more likely to receive AST compared to younger age groups (OR 1.32 CI 1.11 to 1.56). Patients with ER visit longer than 9 hours were more likely to receive AST compared to shorter ER visits (OR 1.82 CI 1.43 to 2.30). Patients with severe abdominal pain were more likely to receive AST compared to patients with milder degree of pain (OR 1.37 CI 1.08 to 1.74). Conclusion: Age, gender differences, length of ER visit and severity of abdominal pain have significant impact on the prescription of AST for the treatment of abdominal pain in ER. The higher prevalence of gastritis/ ulcers in men and presence of additional sources of abdominal pain in women could explain the higher prescription rate in men. Middle aged patients have higher AST prescription rate which probably reflects the higher prevalence of upper GI pathology as patients get older. A tendency to prescribe AST when a definite diagnosis is not reached or when pain is refractory could explain the higher prescription rates in patients with longer ER visits and severe abdominal pain. Further studies are needed to investigate and frame guidelines for appropriate use of AST. Tu1078 The Role of Confocal Laser Endomicroscopy in the Management of Patients With Barrett's Esophagus: A Clinical Evidence-Based Consensus Report Kenneth K. Wang, Razvan Arsenescu, Helga Bertani, Fabrice Caillol, David L. Carr-Locke, Kenneth J. Chang, Emmanuel Coron, Aldona Dlugosz, Jean Paul Galmiche, S. Ian Gan, Marc Giovannini, Frank G. Gress, Khek-Yu Ho, Vani J. Konda, Helmut Neumann, Frederic Prat, Prateek Sharma, Satish K. Singh, Herbert C. Wolfsen, Alvin M. Zfass Background: Confocal Laser Endomicroscopy (CLE) is a recent technology that provides microscopic imaging during endoscopy, thus in vivo and in real time. The currently recommended Seattle protocol is intended to provide a comprehensive mapping of the Esophagus, but its inherent constraints have impaired its application. CLE allows for unlimited sampling of the esophageal mucosa and several recently published studies have shown its ability to provide a comprehensive assessment of Barrett's Esophagus (BE) lesions. Objective: To develop consensus recommendations on the role of CLE in the management of patients with BE. Methods: Initial statements on the use of CLE for the characterization of BE were developed by a single CLE expert based on the available clinical evidence. Those preliminary statements were edited and submitted by an external group of 20 GI physicians experts in CLE using a modified Delphi approach. After two rounds of votes based on relevant data, quality of the evidence and strength of recommendation, statements were validated if the threshold of agreement was higher than 75%. Results: 12 recommendations were adopted and 4 were rejected. CLE should be considered in the evaluation of BE. CLE is clinically indicated in patients with BE dysplasia in lesions initially identified with electronic enhancement. CLE is clinically indicated in patients with BE dysplasia in lesions initially endoscopically identified in surveillance. CLE is able to distinguish cardia from intestinal metaplasia (IM), based on the presence/absence of goblet cells. CLE is superior to White-Light Endoscopy (WLE) in identifying IM. A negative CLE random sampling in an endoscopically benign appearing Esophagus is sufficient to reduce the need for a physical biopsy in patients with known BE. CLE can improve the yield for neoplasia compared to standard WLE and random biopsies. CLE and WLE targeted biopsies are superior to WLE targeted biopsies alone in the detection of dysplasia. A positive CLE random sampling in an endoscopically neoplastic appearing Esophagus is sufficient for therapeutic intervention. CLE can be used to define location and lateral extent of neoplasia prior to therapy. CLE should be cited as a valuable tool for an increased diagnostic yield in official surveillance guidelines. CLE should be combined with red flag techniques. Conclusion: The panel of experts that participated in this initiative strongly believes that Confocal Laser Endomicroscopy is an important adjunct to the current endoscopy practice. This technique can improve the management of patients by more accurately characterizing neoplasia, identifying residual neoplasia in post-treatment surveillance and rationalizing the choice of the most appropriate treatment. This consensus report is based on a review of the clinical evidence and on a consensus opinion.
Tu1080 Adherence to Biopsy Guidelines Is Associated With Improved Diagnosis of Celiac Disease and Eosinophilic Esophagitis in Children Thomas E. Wallach, Robert M. Genta, Benjamin Lebwohl, Peter H. Green, Norelle R. Reilly Introduction: Celiac disease (CD) and eosinophilic esophagitis (EoE) are common diagnoses for which pediatric endoscopies are performed. While prior guidelines have recommended a minimum of 4 duodenal biopsy specimens to improve detection of CD, the newly published 2013 American College of Gastroenterology (ACG) guidelines have been amended to also include 2 bulb biopsies for the optimal diagnostic yield. Collecting a minimum of 2 biopsies from 2 separate locations has been recommended to improve the diagnostic yield for EoE. The aim of this study is to assess the frequency with which pediatric endoscopists comply with diagnostic guidelines for CD and EoE. Methods: Deidentified histologic data from patients age 0-18 years collected by a national outpatient clinical pathology laboratory were analyzed. Frequency of adherence to biopsy guidelines for the diagnosis of CD was compared between patients with and without CD, and adherence to recommended practices for the diagnosis of EoE was compared among patients with and without EoE. For continuous variables, t-test and linear regression were used where appropriate. Logistic regression was used to analyze categorical variables. Data analyses were performed using Stata/IC 13.0 for Windows (College Station, TX). Results: We reviewed histologic results from 9171 patients who underwent duodenal biopsy, and 8280 patients who underwent esophageal biopsy. Indications for endoscopy included abdominal pain, vomiting, diarrhea, failure to thrive, dysphagia, dyspepsia, GERD, and anemia. Frequency of adherence to prior diagnostic guidelines for CD was 35.4%, while only 1% of endoscopists would have complied with the more recent 2013 ACG guidelines for CD diagnosis. Diagnostic yield of CD with adequate adherence to prior guidelines was 4.8% versus 9.9% for those adherent to the new ACG guidelines; non-adherence to prior guidelines yielded a CD diagnosis rate of 0.7%, and 2% when considering the 2013 guidelines. Regarding EoE, the frequency of adherence to esophageal biopsy recommendations was 8.2%. EoE diagnosis improved from 7.8% to 24.9% with adherence to current biopsy recommendations. Conclusions: Adherence to diagnostic guidelines significantly improves the ability to detect CD and EoE in children, and adherence to the recent ACG guidelines for CD further increases this diagnostic yield. Index of suspicion related to indication for endoscopy likely plays a role in the endoscopist's decision to biopsy more thoroughly.
Tu1079 Adherence to Surveillance Guidelines in Patients With Barrett's Esophagus (BE): Analysis From a Large Multicenter Cohort Study Srinivas Gaddam, Neil Gupta, Prashanth Vennalaganti, Prashanthi N. Thota, Sachin Wani, April D. Higbee, Sharad C. Mathur, Amit Rastogi, Patrick E. Young, Brooks D. Cash, Ajay Bansal, John J. Vargo, Gary W. Falk, David A. Lieberman, Richard E. Sampliner, Prateek Sharma Background: Despite the controversies, BE surveillance is commonly practiced in the US. However, data on adherence to surveillance interval guidelines are limited. Aim: In a large multicenter cohort of NDBE patients: -To evaluate adherence to surveillance guidelines. -To
AGA Abstracts
S-746
assess for independent predictors of over-surveillance. Methods: This is a multicenter outcomes project (5 centers) of a large cohort of BE patients. BE was defined by columnar metaplasia in the tubular esophagus on endoscopy and intestinal metaplasia on biopsy. Demographics, medication use, family history, and endoscopy results were recorded. Neoplasia was graded as low-grade dysplasia (LGD), high-grade dysplasia (HGD) and EAC. Adherence was defined as a repeat endoscopy within 1-3 years of diagnosis for NDBE and within 6-12 months for LGD. Over-surveillance was defined as undergoing endoscopic surveillance before the above defined surveillance intervals. Fisher's exact test and Mann-Whitney U test were used to compare categorical and continuous variables, respectively. Factors significant on univariate analysis were examined using a stepwise, multivariate logistic regression model to examine predictors for over-surveillance. Results: 3635 patients were included in the analysis [87.8% males, 92.8% Caucasians, mean BMI 28.4 (SD 6.1), mean age 60.9 (SD 12.3), and mean BE length 3.5 cm (SD 3.3)]. On the initial diagnostic endoscopy, 2237 patients were found to have BE without dysplasia (NDBE) and 378 patients were found to have LGD. Of the NDBE patients, 1593 (71.2%) underwent repeat endoscopic surveillance at any point; 22.6% of patients underwent surveillance EGD before the intervals described above. Patients who had LGD were more likely to undergo surveillance endoscopy prior to the recommended period (48% within 6 months, 23% within 6 to 12 months) (Table 1). Comparing patients who were over-surveyed vs. others on univariate analysis, statistically significant differences were seen in age, gender, presence of visible lesion, index histology (NDBE or LGD), and BE length (all p<0.05). No differences in adherence rates were seen based on race, age, or PPI use. On multivariate logistic regression model, patients with LGD on endoscopy were more likely to be over-surveyed [OR = 2.9 (2.2 - 3.7), p<0.01). Other independent predictors included older age, male gender, and the presence of a visible lesion on index endoscopy (Table 2). Conclusions: Despite published guidelines for BE surveillance, overall adherence rates were low even at centers with expertise in BE. Approximately half of the patients with LGD were likely to be over-surveyed. Given the low reproducibility of LGD diagnosis, this potentially represents a significant burden to the health care system. Future studies should evaluate patient and physician factors affecting adherence to BE surveillance guidelines.
AGA Abstracts
Abdominal Pain and Factors Influencing Prescription Patterns of Proton Pump Inhibitors in Emergency Room Visits Arunkumar Muthusamy, Palaniappan Manickam Background: Abdominal pain is a common reason for ER visits. Acid suppression therapy (AST) using proton pump inhibitors and H2-blockers is commonly prescribed in ER for abdominal pain. As inappropriate use of AST can contribute to drug interactions, pneumonia, and increased health care expenditure, we wanted to look for factors which influence prescribing patterns of AST in ER. Objectives: To evaluate if age, gender differences, severity of abdominal pain and length of ER stay influence prescription of acid suppression therapy (AST) in patients presenting to ER with abdominal pain. Methods: We analyzed the limited access dataset of National Hospital Ambulatory Medical Care Survey (2006 to 2009) for ER visits. We included all patients above 15 years of age presenting to ER with upper abdominal pain. We calculated and compared AST prescription rates based on age, gender, severity of pain and length of ER visit. Statistical analysis was done using multivariate logistic regression. Results: There were a total of 1, 12,810 patient visits. Of these, 11,496 visits were for abdominal pain consisting of 70% women and 30% men. Men were 36% more likely to receive AST compared to women (OR 1.35 95% CI 1.18 to 1.57). Patients in age group 45-64 years were more likely to receive AST compared to younger age groups (OR 1.32 CI 1.11 to 1.56). Patients with ER visit longer than 9 hours were more likely to receive AST compared to shorter ER visits (OR 1.82 CI 1.43 to 2.30). Patients with severe abdominal pain were more likely to receive AST compared to patients with milder degree of pain (OR 1.37 CI 1.08 to 1.74). Conclusion: Age, gender differences, length of ER visit and severity of abdominal pain have significant impact on the prescription of AST for the treatment of abdominal pain in ER. The higher prevalence of gastritis/ ulcers in men and presence of additional sources of abdominal pain in women could explain the higher prescription rate in men. Middle aged patients have higher AST prescription rate which probably reflects the higher prevalence of upper GI pathology as patients get older. A tendency to prescribe AST when a definite diagnosis is not reached or when pain is refractory could explain the higher prescription rates in patients with longer ER visits and severe abdominal pain. Further studies are needed to investigate and frame guidelines for appropriate use of AST. Tu1078 The Role of Confocal Laser Endomicroscopy in the Management of Patients With Barrett's Esophagus: A Clinical Evidence-Based Consensus Report Kenneth K. Wang, Razvan Arsenescu, Helga Bertani, Fabrice Caillol, David L. Carr-Locke, Kenneth J. Chang, Emmanuel Coron, Aldona Dlugosz, Jean Paul Galmiche, S. Ian Gan, Marc Giovannini, Frank G. Gress, Khek-Yu Ho, Vani J. Konda, Helmut Neumann, Frederic Prat, Prateek Sharma, Satish K. Singh, Herbert C. Wolfsen, Alvin M. Zfass Background: Confocal Laser Endomicroscopy (CLE) is a recent technology that provides microscopic imaging during endoscopy, thus in vivo and in real time. The currently recommended Seattle protocol is intended to provide a comprehensive mapping of the Esophagus, but its inherent constraints have impaired its application. CLE allows for unlimited sampling of the esophageal mucosa and several recently published studies have shown its ability to provide a comprehensive assessment of Barrett's Esophagus (BE) lesions. Objective: To develop consensus recommendations on the role of CLE in the management of patients with BE. Methods: Initial statements on the use of CLE for the characterization of BE were developed by a single CLE expert based on the available clinical evidence. Those preliminary statements were edited and submitted by an external group of 20 GI physicians experts in CLE using a modified Delphi approach. After two rounds of votes based on relevant data, quality of the evidence and strength of recommendation, statements were validated if the threshold of agreement was higher than 75%. Results: 12 recommendations were adopted and 4 were rejected. CLE should be considered in the evaluation of BE. CLE is clinically indicated in patients with BE dysplasia in lesions initially identified with electronic enhancement. CLE is clinically indicated in patients with BE dysplasia in lesions initially endoscopically identified in surveillance. CLE is able to distinguish cardia from intestinal metaplasia (IM), based on the presence/absence of goblet cells. CLE is superior to White-Light Endoscopy (WLE) in identifying IM. A negative CLE random sampling in an endoscopically benign appearing Esophagus is sufficient to reduce the need for a physical biopsy in patients with known BE. CLE can improve the yield for neoplasia compared to standard WLE and random biopsies. CLE and WLE targeted biopsies are superior to WLE targeted biopsies alone in the detection of dysplasia. A positive CLE random sampling in an endoscopically neoplastic appearing Esophagus is sufficient for therapeutic intervention. CLE can be used to define location and lateral extent of neoplasia prior to therapy. CLE should be cited as a valuable tool for an increased diagnostic yield in official surveillance guidelines. CLE should be combined with red flag techniques. Conclusion: The panel of experts that participated in this initiative strongly believes that Confocal Laser Endomicroscopy is an important adjunct to the current endoscopy practice. This technique can improve the management of patients by more accurately characterizing neoplasia, identifying residual neoplasia in post-treatment surveillance and rationalizing the choice of the most appropriate treatment. This consensus report is based on a review of the clinical evidence and on a consensus opinion.
Tu1080 Adherence to Biopsy Guidelines Is Associated With Improved Diagnosis of Celiac Disease and Eosinophilic Esophagitis in Children Thomas E. Wallach, Robert M. Genta, Benjamin Lebwohl, Peter H. Green, Norelle R. Reilly Introduction: Celiac disease (CD) and eosinophilic esophagitis (EoE) are common diagnoses for which pediatric endoscopies are performed. While prior guidelines have recommended a minimum of 4 duodenal biopsy specimens to improve detection of CD, the newly published 2013 American College of Gastroenterology (ACG) guidelines have been amended to also include 2 bulb biopsies for the optimal diagnostic yield. Collecting a minimum of 2 biopsies from 2 separate locations has been recommended to improve the diagnostic yield for EoE. The aim of this study is to assess the frequency with which pediatric endoscopists comply with diagnostic guidelines for CD and EoE. Methods: Deidentified histologic data from patients age 0-18 years collected by a national outpatient clinical pathology laboratory were analyzed. Frequency of adherence to biopsy guidelines for the diagnosis of CD was compared between patients with and without CD, and adherence to recommended practices for the diagnosis of EoE was compared among patients with and without EoE. For continuous variables, t-test and linear regression were used where appropriate. Logistic regression was used to analyze categorical variables. Data analyses were performed using Stata/IC 13.0 for Windows (College Station, TX). Results: We reviewed histologic results from 9171 patients who underwent duodenal biopsy, and 8280 patients who underwent esophageal biopsy. Indications for endoscopy included abdominal pain, vomiting, diarrhea, failure to thrive, dysphagia, dyspepsia, GERD, and anemia. Frequency of adherence to prior diagnostic guidelines for CD was 35.4%, while only 1% of endoscopists would have complied with the more recent 2013 ACG guidelines for CD diagnosis. Diagnostic yield of CD with adequate adherence to prior guidelines was 4.8% versus 9.9% for those adherent to the new ACG guidelines; non-adherence to prior guidelines yielded a CD diagnosis rate of 0.7%, and 2% when considering the 2013 guidelines. Regarding EoE, the frequency of adherence to esophageal biopsy recommendations was 8.2%. EoE diagnosis improved from 7.8% to 24.9% with adherence to current biopsy recommendations. Conclusions: Adherence to diagnostic guidelines significantly improves the ability to detect CD and EoE in children, and adherence to the recent ACG guidelines for CD further increases this diagnostic yield. Index of suspicion related to indication for endoscopy likely plays a role in the endoscopist's decision to biopsy more thoroughly.
Tu1079 Adherence to Surveillance Guidelines in Patients With Barrett's Esophagus (BE): Analysis From a Large Multicenter Cohort Study Srinivas Gaddam, Neil Gupta, Prashanth Vennalaganti, Prashanthi N. Thota, Sachin Wani, April D. Higbee, Sharad C. Mathur, Amit Rastogi, Patrick E. Young, Brooks D. Cash, Ajay Bansal, John J. Vargo, Gary W. Falk, David A. Lieberman, Richard E. Sampliner, Prateek Sharma Background: Despite the controversies, BE surveillance is commonly practiced in the US. However, data on adherence to surveillance interval guidelines are limited. Aim: In a large multicenter cohort of NDBE patients: -To evaluate adherence to surveillance guidelines. -To
AGA Abstracts
S-746