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Tu1746 Successful Endoscopic Management of Non Duodenal Small Bowel Varices
Abstracts
to follow up. Data was analyzed using SASv9.4 software. Results: Sixty patients met the study criteria. GOV-2 was the most common gastric varix (48%), with GOV-1 (32%) and IGV-1 (22%) following. We did not have any cases of IGV-2. Thirty-five percent of these patients developed bleeding from GV, and another 10% bled from both GV and EV simultaneously. Of the different types of GV, patients with GOV-2 were most likely to have a GV bleed at 45%, while 32% and 23% of patients with GOV-1 and IGV-1 had GV bleeding, respectively. Overall mortality was 30% in these patients, with a mortality of 10%, 17%, and 22% at 30 days, six months, and one year. In a multivariate regression analysis, diabetes (pZ0.04) and MELD score (pZ0.001) were independent predictors of mortality when controlling for age, smoking and alcohol history, relevant lab values, and other co-morbidities. Conclusions: The presence of gastric varices continues to convey a high mortality and bleeding risk. Although historically, GOV-1 was thought to be the most common gastric varix, our data suggests that fundal varices (GOV-2 and IGV-1) are the most frequently encountered, accounting for 70% of all GV. GOV-2 was also the most likely to bleed. Due to the high mortality and bleeding risk of GV, these patients deserve close monitoring and follow-up. As more research is conducted into primary prevention of GV bleeding, it may be reasonable to consider earlier intervention strategies on higher risk GV.OV-1: Type 1 gastroesophageal varicesGOV-2: Type 2 gastroesophageal varicesIGV-1: Type 1 isolated gastric varicesIGV-2: Type 2 isolated gastric varices
Tu1746 Successful Endoscopic Management of Non Duodenal Small Bowel Varices Toufic Kachaamy*1, Jason D. Adam2, Bimaljit Sandhu3, M. Edwyn Harrison4 1 Gastroenterology, Cancer Treatment Center of America, Phoenix, AZ; 2 VCU, Richmond, VA; 3Richmond Gastroenterology Associates, Richmond, VA; 4Mayo Clinic, Phoenix, AZ Background: Ectopic varices (EV) are defined as varices in the gastrointestinal track outside of the esophagus and the stomach. They are rare manifestation of portosystemic shunts and often represent a challenge in diagnosis and management. The estimated prevalence of EV is estimated to be less than 1 per 2000 ednoscopies. Studies published on EV are limited to case reports and series and mostly include duodenal varices. EV outside the colon and duodenum referred to as small bowel varices (SBV) are extremely rare. Their diagnosis requires deep enteroscopy (DE) as they are difficult to identify on capsule endoscopy. They manifest as refractory bleeding in a patient with portal hypertension and no source identified on upper endoscopy and colonoscopy. The American society of Study of liver disease recommends Transjugular Intrahepatic Portosystemic shunt (TIPS) as the primary treatment modality for EV. This recommendation is based on small uncontrolled studies. TIPS, in addition to the cost, has multiple potential adverse events including the risk of worsening postosystemic shunting and encephalopathy. The mainstay of endoscopic management of EV is obliteration via cyanoacrylate injection (CI). SBV endoscopic management requires DE. The rarity of SBV together with the lack of availability of urgent DE combined with the skills to perform CI has limited studies on endoscopic management of SBV to isolated case reports. We are presenting a series of successful endoscopic management of SBV. Methods: All patients undergoing DE and CI in three tertiary care referral centers between 2007 and 2014 were identified. The clinical manifestations, treatment and outcomes were reviewed. Results: 6 procedures were performed on 5 patients. 4 of the 5 patients had altered gastrointestinal anatomy. All patients had cirrhosis and portal hypertension. All patients required hospital admission with multiple blood transfusions. They underwent an upper endoscopy and colonoscopy with no source of bleeding identified. Small bowel evaluations were positive bleeding scans on 4 patients. One patient underwent triple phase CT, bleeding scan and a capsule endoscopy all of which were negative for bleeding or varices. DE was performed on all and identified SBV with stigmata of bleeding. CI was performed in all 5 patients. Bleeding was controlled with no recurrence in 4 patients. One patient required a repeat enteroscopy with CI within 4 weeks which controlled the bleeding. No procedural related adverse events occurred. Conclusion: Non duodenal small bowel varices bleeding is extremely rare. Successful endoscopic management is possible with low risk of adverse events. It requires a multidisciplinary approach with the availability of urgent deep bowel enteroscopy and cyanoacrylate injection.
www.giejournal.org
Tu1747 Practice Variation in Percutaneous Endoscopic Gastrostomy Tube Placement: Trends and Predictors Among Providers in the United States Lukejohn W. Day*2,1, Michelle Nazareth3, Justin L. Sewell2,1, Jeffrey L. Williams4, David A. Lieberman4 1 Gastroenterology, UCSF, San Francisco, CA; 2Medicine, GI, San Francisco General Hospital, San Francisco, CA; 3GI, Kaiser Permanente, Modesto, CA; 4GI, Oregon Health & Science University, Portland, OR Background: Enteral access placement is performed among a variety of providers and specialties, yet there is limited literature on trends and factors related to it being performed in the U.S. Our objectives were to: (1) determine the incidence of enteral access placement over time in the U.S., and (2) identify provider-, patient-, and setting-related factors predicting enteral access placement. Methods: Retrospective review of upper endoscopic procedures that involved percutaneous endoscopic gastrostomy (PEG) tube placement between 2000-2010 among endoscopy sites participating in the Clinical Outcomes Research Initiative (CORI) was performed. Annual PEG tube incidence was calculated and multivariate logistic regression analysis was used to determine predictors of PEG tube placement in the U.S. Results: From 2000-2010, PEG tube placement was performed in 1.5% of upper endoscopic procedures (number of PEG tubes performed (NZ12,227)/number of upper endoscopies performed (NZ824,453)) with the majority of them being performed by gastroenterologists (82.7%). Mean age of patients receiving a PEG tube was 62.7 24.3 years; nearly half of all PEG tubes were placed in patients over the age of 70 (48.6%). PEG tubes were placed in 3.8% of EGDs in Blacks, 1.7% of EGDs in Hispanics, and 1.2% of EGDs in Whites. PEG tube placement occurred less frequently in academic (OR 0.92, 95% CI 0.87-0.97) or VA/military hospital (OR 0.66, 95% CI 0.62-0.71) settings compared to community/HMO settings. Inpatients were almost eight times more likely to receive a PEG tube compared with outpatients (OR 7.91, 95% CI 7.56-8.28). With respect to provider characteristics, there was a trend that as providers were further out of medical school they were less likely to perform a PEG tube procedure (compared to 3-9 years out of medical school: 10-19 years OR 0.98, 95% CI 0.92-1.05; 20-29 years OR 0.79, 95% CI 0.73-0.84; 30-39 years OR 0.67, 95% CI 0.62-0.73). Conclusions: To date, this is the largest survey of PEG tube utilization in the U.S. Significant practice variation was noted in PEG tube placement with respect to patient and provider characteristics and endoscopy settings. Now that we have characterized the demographics of patients receiving PEG tubes, further research is needed to determine if PEG tubes benefit in terms of nutrition, survival and quality of life.
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB581
to follow up. Data was analyzed using SASv9.4 software. Results: Sixty patients met the study criteria. GOV-2 was the most common gastric varix (48%), with GOV-1 (32%) and IGV-1 (22%) following. We did not have any cases of IGV-2. Thirty-five percent of these patients developed bleeding from GV, and another 10% bled from both GV and EV simultaneously. Of the different types of GV, patients with GOV-2 were most likely to have a GV bleed at 45%, while 32% and 23% of patients with GOV-1 and IGV-1 had GV bleeding, respectively. Overall mortality was 30% in these patients, with a mortality of 10%, 17%, and 22% at 30 days, six months, and one year. In a multivariate regression analysis, diabetes (pZ0.04) and MELD score (pZ0.001) were independent predictors of mortality when controlling for age, smoking and alcohol history, relevant lab values, and other co-morbidities. Conclusions: The presence of gastric varices continues to convey a high mortality and bleeding risk. Although historically, GOV-1 was thought to be the most common gastric varix, our data suggests that fundal varices (GOV-2 and IGV-1) are the most frequently encountered, accounting for 70% of all GV. GOV-2 was also the most likely to bleed. Due to the high mortality and bleeding risk of GV, these patients deserve close monitoring and follow-up. As more research is conducted into primary prevention of GV bleeding, it may be reasonable to consider earlier intervention strategies on higher risk GV.OV-1: Type 1 gastroesophageal varicesGOV-2: Type 2 gastroesophageal varicesIGV-1: Type 1 isolated gastric varicesIGV-2: Type 2 isolated gastric varices
Tu1746 Successful Endoscopic Management of Non Duodenal Small Bowel Varices Toufic Kachaamy*1, Jason D. Adam2, Bimaljit Sandhu3, M. Edwyn Harrison4 1 Gastroenterology, Cancer Treatment Center of America, Phoenix, AZ; 2 VCU, Richmond, VA; 3Richmond Gastroenterology Associates, Richmond, VA; 4Mayo Clinic, Phoenix, AZ Background: Ectopic varices (EV) are defined as varices in the gastrointestinal track outside of the esophagus and the stomach. They are rare manifestation of portosystemic shunts and often represent a challenge in diagnosis and management. The estimated prevalence of EV is estimated to be less than 1 per 2000 ednoscopies. Studies published on EV are limited to case reports and series and mostly include duodenal varices. EV outside the colon and duodenum referred to as small bowel varices (SBV) are extremely rare. Their diagnosis requires deep enteroscopy (DE) as they are difficult to identify on capsule endoscopy. They manifest as refractory bleeding in a patient with portal hypertension and no source identified on upper endoscopy and colonoscopy. The American society of Study of liver disease recommends Transjugular Intrahepatic Portosystemic shunt (TIPS) as the primary treatment modality for EV. This recommendation is based on small uncontrolled studies. TIPS, in addition to the cost, has multiple potential adverse events including the risk of worsening postosystemic shunting and encephalopathy. The mainstay of endoscopic management of EV is obliteration via cyanoacrylate injection (CI). SBV endoscopic management requires DE. The rarity of SBV together with the lack of availability of urgent DE combined with the skills to perform CI has limited studies on endoscopic management of SBV to isolated case reports. We are presenting a series of successful endoscopic management of SBV. Methods: All patients undergoing DE and CI in three tertiary care referral centers between 2007 and 2014 were identified. The clinical manifestations, treatment and outcomes were reviewed. Results: 6 procedures were performed on 5 patients. 4 of the 5 patients had altered gastrointestinal anatomy. All patients had cirrhosis and portal hypertension. All patients required hospital admission with multiple blood transfusions. They underwent an upper endoscopy and colonoscopy with no source of bleeding identified. Small bowel evaluations were positive bleeding scans on 4 patients. One patient underwent triple phase CT, bleeding scan and a capsule endoscopy all of which were negative for bleeding or varices. DE was performed on all and identified SBV with stigmata of bleeding. CI was performed in all 5 patients. Bleeding was controlled with no recurrence in 4 patients. One patient required a repeat enteroscopy with CI within 4 weeks which controlled the bleeding. No procedural related adverse events occurred. Conclusion: Non duodenal small bowel varices bleeding is extremely rare. Successful endoscopic management is possible with low risk of adverse events. It requires a multidisciplinary approach with the availability of urgent deep bowel enteroscopy and cyanoacrylate injection.
www.giejournal.org
Tu1747 Practice Variation in Percutaneous Endoscopic Gastrostomy Tube Placement: Trends and Predictors Among Providers in the United States Lukejohn W. Day*2,1, Michelle Nazareth3, Justin L. Sewell2,1, Jeffrey L. Williams4, David A. Lieberman4 1 Gastroenterology, UCSF, San Francisco, CA; 2Medicine, GI, San Francisco General Hospital, San Francisco, CA; 3GI, Kaiser Permanente, Modesto, CA; 4GI, Oregon Health & Science University, Portland, OR Background: Enteral access placement is performed among a variety of providers and specialties, yet there is limited literature on trends and factors related to it being performed in the U.S. Our objectives were to: (1) determine the incidence of enteral access placement over time in the U.S., and (2) identify provider-, patient-, and setting-related factors predicting enteral access placement. Methods: Retrospective review of upper endoscopic procedures that involved percutaneous endoscopic gastrostomy (PEG) tube placement between 2000-2010 among endoscopy sites participating in the Clinical Outcomes Research Initiative (CORI) was performed. Annual PEG tube incidence was calculated and multivariate logistic regression analysis was used to determine predictors of PEG tube placement in the U.S. Results: From 2000-2010, PEG tube placement was performed in 1.5% of upper endoscopic procedures (number of PEG tubes performed (NZ12,227)/number of upper endoscopies performed (NZ824,453)) with the majority of them being performed by gastroenterologists (82.7%). Mean age of patients receiving a PEG tube was 62.7 24.3 years; nearly half of all PEG tubes were placed in patients over the age of 70 (48.6%). PEG tubes were placed in 3.8% of EGDs in Blacks, 1.7% of EGDs in Hispanics, and 1.2% of EGDs in Whites. PEG tube placement occurred less frequently in academic (OR 0.92, 95% CI 0.87-0.97) or VA/military hospital (OR 0.66, 95% CI 0.62-0.71) settings compared to community/HMO settings. Inpatients were almost eight times more likely to receive a PEG tube compared with outpatients (OR 7.91, 95% CI 7.56-8.28). With respect to provider characteristics, there was a trend that as providers were further out of medical school they were less likely to perform a PEG tube procedure (compared to 3-9 years out of medical school: 10-19 years OR 0.98, 95% CI 0.92-1.05; 20-29 years OR 0.79, 95% CI 0.73-0.84; 30-39 years OR 0.67, 95% CI 0.62-0.73). Conclusions: To date, this is the largest survey of PEG tube utilization in the U.S. Significant practice variation was noted in PEG tube placement with respect to patient and provider characteristics and endoscopy settings. Now that we have characterized the demographics of patients receiving PEG tubes, further research is needed to determine if PEG tubes benefit in terms of nutrition, survival and quality of life.
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB581