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Tu1421 Safety of PEG-ELS in Individuals Who Previously Underwent Heart Transplantation
Abstracts
rate have mostly focused on diverse purgative agents and/or regimens. An alternative but un-tested approach would be to preemptively identify patients who are likely to present with poor preparation. Objective: To investigate the safety and diagnostic accuracy of pre-colonoscopy ingestion of radio-opaque markers for pre-procedural identification of sub-optimal colon preparation. Methods: This was a pilot prospective investigator-blinded study in a tertiary referral center including hospitalized patients referred to colonoscopy. All patients ingested two doses of radio-opaque Sitzmarks™ markers within 20 hours before commencing bowel preparation, which consisted of 4 liter PEG solution the day before colonoscopy. All patients underwent plain abdominal x-ray on the morning of the colonoscopy, and then colonoscopy with colon cleanliness grading by a blinded endoscopist. The main outcomes were procedure complications and the correlation between the number of passed markers per x-ray and colon cleanliness at colonoscopy. Results: Thirty nine patients were included. There were no complications in any patient and tolerability of markers was excellent. There was modest correlation (r⫽0.33, p⫽0.04) between the total number of retained markers and the degree of actual colon cleanliness at colonoscopy. Correlation was stronger when only markers retained in the right abdomen were considered (r⫽0.4, p⫽0.01). Conclusions: Ingestion of inert markers in timely fashion with colonoscopy preparation is safe and tolerable. The colonic passage of markers correaltes with preparation quality for colonoscopy. Future studies are needed to optimize this method for preemptive identification of patients with sub-optimal preparation, thereby enabling to selectively target this population for intensified cleansing regimens.
Figure 1. The single significant factor for post-ESD bleeding is the size of a resected specimen over 40 mm: OR⫽4.741, CI⫽2.018-11.141. Tu1420 The Second-Look Endoscopy May Have Significant Role in Detecting Post-ESD Bleeding When the Size of a Resected Specimen Is Over 40 mm Hyung Hun Kim1, Seun Ja Park1, Moo In Park1, Won Moon1, Seok Reyol Choi2 1 Internal medicine, Kosin University College of Medicine, Busan, Republic of Korea; 2Internal medicine, Dong-A Univesrity College of Medicine, Busan, Republic of Korea
Tu1421 Safety of PEG-ELS in Individuals Who Previously Underwent Heart Transplantation Paul Chang, Frank K. Friedenberg Temple University Hospital, Philadelphia, PA
Background and Aims: Endoscopic submucosal dissection (ESD) is a curative endoluminal surgical procedure for the treatment of gastric epithelial neoplasms. One of the major complications of ESD are post-ESD bleeding. In reality, a second-look endoscopy has been routinely performed to check the possibility of post ESD-bleeding in most hospitals without solid evidence. The aim of this study was to evaluate whether a second-look endoscopy was necessary for preventing delayed bleeding and to verify the clinicopathological features of post-ESD bleeding for determining the specific lesions that may need a secondlook endoscopy. Methods: We investigated 440 lesions in 397 patients undergoing ESD for gastric neoplasm at Gospel Hospital, Kosin University College of Medicine, Busan, Korea from January 2008 to June 2010. Post-ESD bleeding was defined as spurting or oozing from the mucosal defect after ESD, as diagnosed by the emergency endoscopy or second-look endoscopy. We reviewed data including underlying disease, endoscopic and pathologic characteristics of lesions, locations of neoplasms, periods of procedures, presence of delayed post-ESD bleeding, and sizes of resected specimens. Furthermore, rate of overall delayed bleeding before and after the second-look endoscopy, performed one of the first three days after ESD, was investigated to determine the usefulness of second-look endoscopy. Results: Delayed post-ESD bleeding was evident in 23 lesions out of 440 lesions, or 5.3% of all specimens and 5.8% of all patients, and all achieved endoscopic hemostasis. Resected specimen width was the only difference between post-ESD bleeding group and control group: 37.26 mm vs. 30.02 mm, p⫽0.001. The single significant factor for post-ESD bleeding was the size of a resected specimen over 40 mm: OR⫽4.741, CI⫽2.018-11.141. All delayed post-ESD bleedings were successfully managed without surgery. Other characteristics of lesions, underlying diseases, or period of procedure were not correlated with delayed post-ESD bleeding. All delayed bleedings occurred by 72 hours after operation. More importantly, 15 out of 23, 65%, delayed bleeding episodes were detected by second-look endoscopies. Conclusions: The second-look endoscopy may have significant role in detecting post-ESD bleeding especially when the size of a resected specimen is over 40 mm.
Background: Colonic preparations containing polyethylene glycol-3350 and a balanced electrolyte solution (PEG-ELS) are considered the safest preparations for individuals with advanced cardiac, renal, or liver disease. We recently reported on the safety of PEG-ELS in subjects with advanced CHF (ACG Annual Meeting 2010; P641) and identified an individual who developed severe, unexplained renal dysfunction post-colonoscopy. The purpose of this study was to examine the renal safety of PEG-ELS in patients status-post cardiac transplantation. Methods: Review of all patients S/P cardiac transplantation that underwent colonoscopy after 4 L PEG-ELS prep in our endoscopy center. We recorded age, gender, and weight for all subjects. Included patients were required to have a metabolic profile 1-6 months prior to and after colonoscopy. We recorded exposure to ACE inhibitors, ARB’s, diuretics, calcineurin inhibitors, and IV dye studies between electrolyte assessments. Results: Overall, 21 patients (13M, 8F), mean age 62.2 ⫾ 10.2, underwent elective colonoscopy after PEG-ELS preparation a mean of 10.4 ⫾ 4.8 years post-transplant. Ten (47.6%) had shown some level of rejection by biopsy in the previous 3 years. Twenty (95.2%) were on a calcineurin inhibitor, six (28.6%) on an ACEI/ARB, and six (28.6%) on a loop diuretic. Three patients (14.3%) had one IV contrast study and one patient had two dye studies between metabolic assessments. For the entire group, estimated Cr clearance did not change from before (56.9 ⫾ 30.6 ml/min) to after (56.0 ⫾ 32.4 ml/min; P⫽0.82) PEG-ELS. Also no difference was seen after stratifying by use of ACEI/ARB, diuretics or peri-procedure dye studies. There was no correlation between age and Cr clearance changes. However, we did find that 3 patients (14.3%) had a deterioration in Cr clearance by ⱖ 25% after the procedure, and one of these deteriorated by 57.1%. Interestingly, this patient was not on an ACEI/ARB or loop diuretic and did not have a contrast dye study. Conclusions: Although as a group we could not identify deterioration in renal function, 3 individuals had a significant, unexplained decline in Cr clearance after exposure to 4L of PEG-ELS. Due to sample size this may represent a Type I error. Age, use of RAA axis drugs, diuretics, or IV contrast could not explain this deterioration. A larger study to assess the safety of PEG-ELS in cardiac transplant patients is warranted.
Date of post-ESD bleeding Date Urgent endoscopy Second-look endoscopy
POD 0
POD 1
POD 2
POD 3
Total
2* 1 3
5 0 5
0 13 13
1 1 2
8 15 23
Abbreviations: ESD, endoscopic submucosal dissection; POD, post operation date. *, n
www.giejournal.org
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB403
rate have mostly focused on diverse purgative agents and/or regimens. An alternative but un-tested approach would be to preemptively identify patients who are likely to present with poor preparation. Objective: To investigate the safety and diagnostic accuracy of pre-colonoscopy ingestion of radio-opaque markers for pre-procedural identification of sub-optimal colon preparation. Methods: This was a pilot prospective investigator-blinded study in a tertiary referral center including hospitalized patients referred to colonoscopy. All patients ingested two doses of radio-opaque Sitzmarks™ markers within 20 hours before commencing bowel preparation, which consisted of 4 liter PEG solution the day before colonoscopy. All patients underwent plain abdominal x-ray on the morning of the colonoscopy, and then colonoscopy with colon cleanliness grading by a blinded endoscopist. The main outcomes were procedure complications and the correlation between the number of passed markers per x-ray and colon cleanliness at colonoscopy. Results: Thirty nine patients were included. There were no complications in any patient and tolerability of markers was excellent. There was modest correlation (r⫽0.33, p⫽0.04) between the total number of retained markers and the degree of actual colon cleanliness at colonoscopy. Correlation was stronger when only markers retained in the right abdomen were considered (r⫽0.4, p⫽0.01). Conclusions: Ingestion of inert markers in timely fashion with colonoscopy preparation is safe and tolerable. The colonic passage of markers correaltes with preparation quality for colonoscopy. Future studies are needed to optimize this method for preemptive identification of patients with sub-optimal preparation, thereby enabling to selectively target this population for intensified cleansing regimens.
Figure 1. The single significant factor for post-ESD bleeding is the size of a resected specimen over 40 mm: OR⫽4.741, CI⫽2.018-11.141. Tu1420 The Second-Look Endoscopy May Have Significant Role in Detecting Post-ESD Bleeding When the Size of a Resected Specimen Is Over 40 mm Hyung Hun Kim1, Seun Ja Park1, Moo In Park1, Won Moon1, Seok Reyol Choi2 1 Internal medicine, Kosin University College of Medicine, Busan, Republic of Korea; 2Internal medicine, Dong-A Univesrity College of Medicine, Busan, Republic of Korea
Tu1421 Safety of PEG-ELS in Individuals Who Previously Underwent Heart Transplantation Paul Chang, Frank K. Friedenberg Temple University Hospital, Philadelphia, PA
Background and Aims: Endoscopic submucosal dissection (ESD) is a curative endoluminal surgical procedure for the treatment of gastric epithelial neoplasms. One of the major complications of ESD are post-ESD bleeding. In reality, a second-look endoscopy has been routinely performed to check the possibility of post ESD-bleeding in most hospitals without solid evidence. The aim of this study was to evaluate whether a second-look endoscopy was necessary for preventing delayed bleeding and to verify the clinicopathological features of post-ESD bleeding for determining the specific lesions that may need a secondlook endoscopy. Methods: We investigated 440 lesions in 397 patients undergoing ESD for gastric neoplasm at Gospel Hospital, Kosin University College of Medicine, Busan, Korea from January 2008 to June 2010. Post-ESD bleeding was defined as spurting or oozing from the mucosal defect after ESD, as diagnosed by the emergency endoscopy or second-look endoscopy. We reviewed data including underlying disease, endoscopic and pathologic characteristics of lesions, locations of neoplasms, periods of procedures, presence of delayed post-ESD bleeding, and sizes of resected specimens. Furthermore, rate of overall delayed bleeding before and after the second-look endoscopy, performed one of the first three days after ESD, was investigated to determine the usefulness of second-look endoscopy. Results: Delayed post-ESD bleeding was evident in 23 lesions out of 440 lesions, or 5.3% of all specimens and 5.8% of all patients, and all achieved endoscopic hemostasis. Resected specimen width was the only difference between post-ESD bleeding group and control group: 37.26 mm vs. 30.02 mm, p⫽0.001. The single significant factor for post-ESD bleeding was the size of a resected specimen over 40 mm: OR⫽4.741, CI⫽2.018-11.141. All delayed post-ESD bleedings were successfully managed without surgery. Other characteristics of lesions, underlying diseases, or period of procedure were not correlated with delayed post-ESD bleeding. All delayed bleedings occurred by 72 hours after operation. More importantly, 15 out of 23, 65%, delayed bleeding episodes were detected by second-look endoscopies. Conclusions: The second-look endoscopy may have significant role in detecting post-ESD bleeding especially when the size of a resected specimen is over 40 mm.
Background: Colonic preparations containing polyethylene glycol-3350 and a balanced electrolyte solution (PEG-ELS) are considered the safest preparations for individuals with advanced cardiac, renal, or liver disease. We recently reported on the safety of PEG-ELS in subjects with advanced CHF (ACG Annual Meeting 2010; P641) and identified an individual who developed severe, unexplained renal dysfunction post-colonoscopy. The purpose of this study was to examine the renal safety of PEG-ELS in patients status-post cardiac transplantation. Methods: Review of all patients S/P cardiac transplantation that underwent colonoscopy after 4 L PEG-ELS prep in our endoscopy center. We recorded age, gender, and weight for all subjects. Included patients were required to have a metabolic profile 1-6 months prior to and after colonoscopy. We recorded exposure to ACE inhibitors, ARB’s, diuretics, calcineurin inhibitors, and IV dye studies between electrolyte assessments. Results: Overall, 21 patients (13M, 8F), mean age 62.2 ⫾ 10.2, underwent elective colonoscopy after PEG-ELS preparation a mean of 10.4 ⫾ 4.8 years post-transplant. Ten (47.6%) had shown some level of rejection by biopsy in the previous 3 years. Twenty (95.2%) were on a calcineurin inhibitor, six (28.6%) on an ACEI/ARB, and six (28.6%) on a loop diuretic. Three patients (14.3%) had one IV contrast study and one patient had two dye studies between metabolic assessments. For the entire group, estimated Cr clearance did not change from before (56.9 ⫾ 30.6 ml/min) to after (56.0 ⫾ 32.4 ml/min; P⫽0.82) PEG-ELS. Also no difference was seen after stratifying by use of ACEI/ARB, diuretics or peri-procedure dye studies. There was no correlation between age and Cr clearance changes. However, we did find that 3 patients (14.3%) had a deterioration in Cr clearance by ⱖ 25% after the procedure, and one of these deteriorated by 57.1%. Interestingly, this patient was not on an ACEI/ARB or loop diuretic and did not have a contrast dye study. Conclusions: Although as a group we could not identify deterioration in renal function, 3 individuals had a significant, unexplained decline in Cr clearance after exposure to 4L of PEG-ELS. Due to sample size this may represent a Type I error. Age, use of RAA axis drugs, diuretics, or IV contrast could not explain this deterioration. A larger study to assess the safety of PEG-ELS in cardiac transplant patients is warranted.
Date of post-ESD bleeding Date Urgent endoscopy Second-look endoscopy
POD 0
POD 1
POD 2
POD 3
Total
2* 1 3
5 0 5
0 13 13
1 1 2
8 15 23
Abbreviations: ESD, endoscopic submucosal dissection; POD, post operation date. *, n
www.giejournal.org
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB403