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Tu1554 Interobserver Agreement for Confocal Imaging of Ampullary Lesions: A Multicenter Single Blinded Study
Abstracts
good feasibility may take a transitional role before initiating ESD method in the treatment of colorectal neoplasia.
Tu1552 How Often Do We Miss Polyps During Colonoscopy? Sergey V. Kantsevoy, Endashaw Omer, Andrew Zhigalin, Sanjay Jagannath, Anurag Maheshwari, Paul J. Thuluvath Gastroenterology, Institute for Digestive Health and Liver Disease at Mercy Medical Center, Baltimore, MD Background: Screening colonoscopy have become a gold standard and a cornerstone in colon cancer prevention. However, adequacy of the colonoscopy depends on the ability of the gastroenterologist to detect all pre-cancerous colonic lesions and true rate of missing polyps is still unknown. Aim: To determine the polyp miss rate during conventional colonoscopy. Methods: We followed prospectively all patients who were referred for endoscopic removal of large colonic polyps to Mercy Medical Center from October 2008 till October 2010. All additional polyps found during colonoscopy in our center and not seen during the prior colonoscopy were considered missed during the initial colonoscopy. A follow-up colonoscopy in 3 months after removal of the large polyp was recommended to all patients to rule out any residual polypoid tissue at the polypectomy site. At that time the entire colon was examined again to confirm the absence of any additional polyps. Location, size, number of polyps, results of histological examination and time between colonoscopic examinations were entered into Excel database for subsequent analysis. Results: We performed colonoscopy to remove previously found large colonic polyps in 149 patients. Large polyps found on initial colonoscopy varied in size from 2 to 7 cm (mean 3.1 ⫾ 1.2 cm). In addition to the large polyps, 68 more polyps (31.3%) were missed during the first colonoscopy and found only during endoscopic removal of the large polyps: 1 more polyp was found in 35 patients, 2 more polyps were found in 7 patients and 3 and more polyps were found in 4 patients. Missed polyps varied in size from 0.3 cm to 4 cm. Histological examination revealed tubular adenomas, tubulo-villous adenomas and mixed serrated adenomas in majority of the missed polyps. In total, additional polyps were missed in 46 patients (30.9%). Conclusion: Polyp miss rate during standard colonoscopy is still unacceptably high.
Tu1553 Irsogladine, a Gastroprotective Drug, Protects Against NSAID-Induced Esophagitis, Peptic Ulcers, and Small Intestinal Mucosal Damages in Healthy Subjects: A Prospective Randomised Study of Comparison With Omeprazole Takanori Kuramoto, Eiji Umegaki, Yuichi Kojima, Ken Narabayashi, Sadaharu Nouda, Yukiko Yoda, Kumi Ishida, Ken Kawakami, Toshihisa Takeuchi, Takuya Inoue, Mitsuyuki Murano, Satoshi Tokioka, Kazuhide Higuchi 2nd department of Internal Medicine, Osaka Medical College, Takatsuki, Osaka, Japan
Background: Malignant ampullary lesions can be difficult to classify by endoscopy alone. Probe-based confocal endomicroscopy (pCLE) using the IV contrast agent, fluorescein permits in vivo, near-histopathology-grade microscopic assessment of mucosal structures in the GI and hepatobiliary tracts in real time. The objective of this pilot multicenter study was to assess the interobserver agreement and variance in interpretation of pCLE of ampullary lesions. Methods: In an IRB approved study, twelve pCLE video clips of ampullary lesions were distributed to 6 GI specialists at 5 medical centers, blinded to final pathologic results. Seven variables were assessed for interobserver agreement using the kappa statistic. Variables included an epithelial outer border with irregular thickness, dark epithelium without discernable individual cells, heterogeneously distributed elongated crypts reduced number of goblet cells, neovascularization, and final diagnoses (See Table 1). K statistics were interpreted based on the convention by Landis and Koch: poor agreement ⬍⫽0; slight agreement: 0 to 0.20; fair agreement: 0.21 to 0.40; moderate agreement: 0.41 to 0.60; substantial agreement: 0.61 to 0.80; almost perfect agreement: 0.81 to 1.0. Based on prior image interpretation experience, observers were categorized into 3 categories (Category 1: 0-10; Category 2: 1120; Category 3: ⬎ 21 cases) Results: The overall interobserver agreement for all observers was ’poor’ for all variables (k⫽0.02; k⫽0.05, k⫽ ⫺ 0.01, k⫽0.04, k⫽0. 018) except for the first variable that had a ’fair’ degree of agreement (k⫽0.27). Based on experience, 3 observers belonged to the less-experienced category, while the other 3 belonged to the most-experienced category. Upon stratification, the less-experienced raters had poor interobserver agreement for all variables. The most experienced raters had poor interobserver agreement for all variables except for the final diagnosis, which had a fair degree of agreement (see Table 1). Conclusion: This is the first study to assess the utility of pCLE in ampullary lesions and compare interpretation. The overall interobserver agreement on pCLE interpretation for ampullary lesions was poor. The interobserver agreement was not substantially improved for experienced raters. Further standardization of pCLE image criteria is needed. Standardized training may improve inter-rater reliability to an acceptable level. Interobserver Agreement for all observers and by Category
Background: The emergence of capsule endoscopy and double balloon endoscopy has allowed small intestinal lesions to be identified. Non-steroidal anti-inflammatory drug (NSAIDs) may induce small intestinal mucosal injury as a source of obscure gastrointestinal bleeding (OGIB). Proton pump inhibitors (PPI) are now the drugs of first choice during treatment with NSAIDs for peptic ulcers. However, strategy of treatment and prevention of intestinal small lesions should be immediately established, since PPI are probably not effective for them. We previously reported that irsogladine maleate, a widely used gastroprotective drug significantly inhibits indomethacin-induced small intestinal mucosal injury in rats (AGA 2008). In the present study, we planned to clinically confirm the efficacy of irsogladine compared to PPI. Methods: Healthy adult volunteers deemed eligible based on interview and other criteria were randomly divided into 2 groups (Group I: diclofenac Na 75 mg/day ⫹ irsogladine 4 mg/day, Group O: diclofenac Na 75 mg/day ⫹ omeprazole 10 mg/day) (16 subjects in each group). Diagnosis of lesions, biochemical test values, occult blood (on chemical/ immunological testing), and fecal calprotectin level were compared using esophagogastroduodenoscopy (EGD) and capsule endoscopy at the start and end of treatment (after 2 weeks). Results: On measurement of numbers of small intestinal mucosal lesions (erythema, erosion, and ulcers), irsogladine significantly protected small intestinal mucosa from erosion (p⫽0.011) and ulcers (p⫽0.036). There was no significant difference between groups in Lanza score and Los Angeles criteria. However, fecal calprotectin level was significantly increased in Group O (p⫽0.038). Conclusion: There was no significant difference in rate of inhibition of NSAIDs induced lesions formation between irsogladine and PPI in the esophagus, stomach, or duodenum, although irsogladine significantly inhibited lesion formation compared with PPI in the small intestine. These findings suggest that irsogladine, unlike PPI, can protect the GI tract from the esophagus to small intestine as a single agent, and that it may be very useful during treatment with NSAIDs considering its cost-effectiveness.
www.giejournal.org
Tu1554 Interobserver Agreement for Confocal Imaging of Ampullary Lesions: A Multicenter Single Blinded Study Mihir R. Bakhru1, Amrita Sethi2, Priya A. Jamidar3, Satish K. Singh4, Richard S. Kwon5, Uzma D. Siddiqui3, Mandeep Sawhney6, Jayant P. Talreja1, Monica Gaidhane1, Bryan G. Sauer1, Michel Kahaleh1 1 Digestive Health, University of Virginia, Charlottesville, VA; 2 Gastroenterology, Columbia University Medical Center, New York, NY; 3 Gastroenterology, Yale, New Haven, CT; 4Gastroenterology, Boston University School of Medicine, Boston, MA; 5Gastroenterology, University of Michigan, Ann Arbor, MI; 6Gastroenterology, BIDMC, Boston, MA
Variable Outer border with irregular thickness Darkness of the epithelial border where cells cannot be distinguished Elongated crypts Reduced number of goblet cells New vascularization Final diagnosis (Benign, Malignant, Indeterminant)
All
Categorie 1
Categorie 2 and 3
Kappa 0.27 0.02
Kappa 0.19 ⫺0.15
Kappa 0.18 0.04
0.05 ⫺0.01 0.04 0.02
⫺0.06 ⫺0.10 ⫺0.01 ⫺0.2
0.15 ⫺0.05 ⫺0.06 0.21
Tu1555 Therapeutic Small Bowel Endoscopy Using Balloon-Assisted Enteroscopy: A Bi-National, Three-Center Experience Ivan Jovanovic1,2, Lucia C. Fry2,3, Klaus Vormbrock2, Srdjan Djuranovic1, Milenko Ugljesic1, Marzena Zabielski2, Peter Malfertheiner3, Klaus Monkemuller23 1 Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia; 2 Gastroenterology, Marienhospital Bottrop, Bottrop, Germany; 3 Gastroenterology, Otto-von-Guericke University, Magdeburg, Germany Background: Capsule endoscopy and device-assisted enteroscopy using balloonand spiral methods have increased our ability to investigate the small bowel. The increased use of these devices has been paralleled with the discovery of conditions that can be treated endoscopically. There are few reports focusing on therapeutic small bowel endoscopy. Aims: To analyze the results of therapeutic
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB445
good feasibility may take a transitional role before initiating ESD method in the treatment of colorectal neoplasia.
Tu1552 How Often Do We Miss Polyps During Colonoscopy? Sergey V. Kantsevoy, Endashaw Omer, Andrew Zhigalin, Sanjay Jagannath, Anurag Maheshwari, Paul J. Thuluvath Gastroenterology, Institute for Digestive Health and Liver Disease at Mercy Medical Center, Baltimore, MD Background: Screening colonoscopy have become a gold standard and a cornerstone in colon cancer prevention. However, adequacy of the colonoscopy depends on the ability of the gastroenterologist to detect all pre-cancerous colonic lesions and true rate of missing polyps is still unknown. Aim: To determine the polyp miss rate during conventional colonoscopy. Methods: We followed prospectively all patients who were referred for endoscopic removal of large colonic polyps to Mercy Medical Center from October 2008 till October 2010. All additional polyps found during colonoscopy in our center and not seen during the prior colonoscopy were considered missed during the initial colonoscopy. A follow-up colonoscopy in 3 months after removal of the large polyp was recommended to all patients to rule out any residual polypoid tissue at the polypectomy site. At that time the entire colon was examined again to confirm the absence of any additional polyps. Location, size, number of polyps, results of histological examination and time between colonoscopic examinations were entered into Excel database for subsequent analysis. Results: We performed colonoscopy to remove previously found large colonic polyps in 149 patients. Large polyps found on initial colonoscopy varied in size from 2 to 7 cm (mean 3.1 ⫾ 1.2 cm). In addition to the large polyps, 68 more polyps (31.3%) were missed during the first colonoscopy and found only during endoscopic removal of the large polyps: 1 more polyp was found in 35 patients, 2 more polyps were found in 7 patients and 3 and more polyps were found in 4 patients. Missed polyps varied in size from 0.3 cm to 4 cm. Histological examination revealed tubular adenomas, tubulo-villous adenomas and mixed serrated adenomas in majority of the missed polyps. In total, additional polyps were missed in 46 patients (30.9%). Conclusion: Polyp miss rate during standard colonoscopy is still unacceptably high.
Tu1553 Irsogladine, a Gastroprotective Drug, Protects Against NSAID-Induced Esophagitis, Peptic Ulcers, and Small Intestinal Mucosal Damages in Healthy Subjects: A Prospective Randomised Study of Comparison With Omeprazole Takanori Kuramoto, Eiji Umegaki, Yuichi Kojima, Ken Narabayashi, Sadaharu Nouda, Yukiko Yoda, Kumi Ishida, Ken Kawakami, Toshihisa Takeuchi, Takuya Inoue, Mitsuyuki Murano, Satoshi Tokioka, Kazuhide Higuchi 2nd department of Internal Medicine, Osaka Medical College, Takatsuki, Osaka, Japan
Background: Malignant ampullary lesions can be difficult to classify by endoscopy alone. Probe-based confocal endomicroscopy (pCLE) using the IV contrast agent, fluorescein permits in vivo, near-histopathology-grade microscopic assessment of mucosal structures in the GI and hepatobiliary tracts in real time. The objective of this pilot multicenter study was to assess the interobserver agreement and variance in interpretation of pCLE of ampullary lesions. Methods: In an IRB approved study, twelve pCLE video clips of ampullary lesions were distributed to 6 GI specialists at 5 medical centers, blinded to final pathologic results. Seven variables were assessed for interobserver agreement using the kappa statistic. Variables included an epithelial outer border with irregular thickness, dark epithelium without discernable individual cells, heterogeneously distributed elongated crypts reduced number of goblet cells, neovascularization, and final diagnoses (See Table 1). K statistics were interpreted based on the convention by Landis and Koch: poor agreement ⬍⫽0; slight agreement: 0 to 0.20; fair agreement: 0.21 to 0.40; moderate agreement: 0.41 to 0.60; substantial agreement: 0.61 to 0.80; almost perfect agreement: 0.81 to 1.0. Based on prior image interpretation experience, observers were categorized into 3 categories (Category 1: 0-10; Category 2: 1120; Category 3: ⬎ 21 cases) Results: The overall interobserver agreement for all observers was ’poor’ for all variables (k⫽0.02; k⫽0.05, k⫽ ⫺ 0.01, k⫽0.04, k⫽0. 018) except for the first variable that had a ’fair’ degree of agreement (k⫽0.27). Based on experience, 3 observers belonged to the less-experienced category, while the other 3 belonged to the most-experienced category. Upon stratification, the less-experienced raters had poor interobserver agreement for all variables. The most experienced raters had poor interobserver agreement for all variables except for the final diagnosis, which had a fair degree of agreement (see Table 1). Conclusion: This is the first study to assess the utility of pCLE in ampullary lesions and compare interpretation. The overall interobserver agreement on pCLE interpretation for ampullary lesions was poor. The interobserver agreement was not substantially improved for experienced raters. Further standardization of pCLE image criteria is needed. Standardized training may improve inter-rater reliability to an acceptable level. Interobserver Agreement for all observers and by Category
Background: The emergence of capsule endoscopy and double balloon endoscopy has allowed small intestinal lesions to be identified. Non-steroidal anti-inflammatory drug (NSAIDs) may induce small intestinal mucosal injury as a source of obscure gastrointestinal bleeding (OGIB). Proton pump inhibitors (PPI) are now the drugs of first choice during treatment with NSAIDs for peptic ulcers. However, strategy of treatment and prevention of intestinal small lesions should be immediately established, since PPI are probably not effective for them. We previously reported that irsogladine maleate, a widely used gastroprotective drug significantly inhibits indomethacin-induced small intestinal mucosal injury in rats (AGA 2008). In the present study, we planned to clinically confirm the efficacy of irsogladine compared to PPI. Methods: Healthy adult volunteers deemed eligible based on interview and other criteria were randomly divided into 2 groups (Group I: diclofenac Na 75 mg/day ⫹ irsogladine 4 mg/day, Group O: diclofenac Na 75 mg/day ⫹ omeprazole 10 mg/day) (16 subjects in each group). Diagnosis of lesions, biochemical test values, occult blood (on chemical/ immunological testing), and fecal calprotectin level were compared using esophagogastroduodenoscopy (EGD) and capsule endoscopy at the start and end of treatment (after 2 weeks). Results: On measurement of numbers of small intestinal mucosal lesions (erythema, erosion, and ulcers), irsogladine significantly protected small intestinal mucosa from erosion (p⫽0.011) and ulcers (p⫽0.036). There was no significant difference between groups in Lanza score and Los Angeles criteria. However, fecal calprotectin level was significantly increased in Group O (p⫽0.038). Conclusion: There was no significant difference in rate of inhibition of NSAIDs induced lesions formation between irsogladine and PPI in the esophagus, stomach, or duodenum, although irsogladine significantly inhibited lesion formation compared with PPI in the small intestine. These findings suggest that irsogladine, unlike PPI, can protect the GI tract from the esophagus to small intestine as a single agent, and that it may be very useful during treatment with NSAIDs considering its cost-effectiveness.
www.giejournal.org
Tu1554 Interobserver Agreement for Confocal Imaging of Ampullary Lesions: A Multicenter Single Blinded Study Mihir R. Bakhru1, Amrita Sethi2, Priya A. Jamidar3, Satish K. Singh4, Richard S. Kwon5, Uzma D. Siddiqui3, Mandeep Sawhney6, Jayant P. Talreja1, Monica Gaidhane1, Bryan G. Sauer1, Michel Kahaleh1 1 Digestive Health, University of Virginia, Charlottesville, VA; 2 Gastroenterology, Columbia University Medical Center, New York, NY; 3 Gastroenterology, Yale, New Haven, CT; 4Gastroenterology, Boston University School of Medicine, Boston, MA; 5Gastroenterology, University of Michigan, Ann Arbor, MI; 6Gastroenterology, BIDMC, Boston, MA
Variable Outer border with irregular thickness Darkness of the epithelial border where cells cannot be distinguished Elongated crypts Reduced number of goblet cells New vascularization Final diagnosis (Benign, Malignant, Indeterminant)
All
Categorie 1
Categorie 2 and 3
Kappa 0.27 0.02
Kappa 0.19 ⫺0.15
Kappa 0.18 0.04
0.05 ⫺0.01 0.04 0.02
⫺0.06 ⫺0.10 ⫺0.01 ⫺0.2
0.15 ⫺0.05 ⫺0.06 0.21
Tu1555 Therapeutic Small Bowel Endoscopy Using Balloon-Assisted Enteroscopy: A Bi-National, Three-Center Experience Ivan Jovanovic1,2, Lucia C. Fry2,3, Klaus Vormbrock2, Srdjan Djuranovic1, Milenko Ugljesic1, Marzena Zabielski2, Peter Malfertheiner3, Klaus Monkemuller23 1 Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia; 2 Gastroenterology, Marienhospital Bottrop, Bottrop, Germany; 3 Gastroenterology, Otto-von-Guericke University, Magdeburg, Germany Background: Capsule endoscopy and device-assisted enteroscopy using balloonand spiral methods have increased our ability to investigate the small bowel. The increased use of these devices has been paralleled with the discovery of conditions that can be treated endoscopically. There are few reports focusing on therapeutic small bowel endoscopy. Aims: To analyze the results of therapeutic
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB445