- Email: [email protected]
W1033 Seasonal Variation in the Incidence of Eosinophilic Esophagitis Over 30 Years : A Population Based Study
statistics. Results: 3456 patient charts were reviewed: 82 patients with EE were identified, of which 26 (32%) were children. 52% of patients had a history of documented seasonal allergies and 23% had a history of asthma as well. The distribution of the month of diagnosis is shown in figure 1 showing the results of the Rayleigh circular statistic test: this revealed a nonrandom diagnosis date distribution, with a “mean direction” indicating a late summer/ early fall preponderance (see Figure 1). Conclusion: Incident cases of EE in the population appear to be diagnosed with disproportionately increased frequency in late summer/fall in Olmsted County Minnesota : this may indicate that inhaled aeroallergens (prevalent during late summer/fall) may have a role in the etiopathogenesis of EE.
Cost Minimization Analysis Comparing Diagnostic Strategies in Unexplained Pancreatitis Charles M. Wilcox, Meredith Kilgore BACKGROUND: Both ERCP and EUS are commonly performed in the evaluation of idiopathic pancreatitis. However, comparative trials of these modalities are lacking and thus the ideal endoscopic diagnostic strategy to evaluate idiopathic pancreatitis remains unknown. METHODS: A decision analysis model of patients with two attacks of unexplained pancreatitis with gallbladder in situ was constructed using Treeage® software. We analyzed cost and overall diagnostic ability of three strategies: endoscopic ultrasonography (EUS), endoscopic retrograde cholangiopancreatography with manometry and bile aspiration (ERCP), and laparoscopic cholecystectomy. The probability of causes of pancreatitis and costs were determined from the medical literature and Medicare fee schedules, respectively. One and two way sensitivity analyses were conducted to identify variables with the greatest effects on model outputs and a probabilistic sensitivity analysis was conducted using Monte Carlo simulation. RESULTS Using the base case analysis, initial EUS was the preferred initial modality for the diagnosis. The expected cost for initial EUS was $4,469 compared with $4,615 for ERCP and $6,268 for laparoscopic cholecystectomy. The findings were robust across a wide probability of microlithiasis / sludge. One and two-way sensitivity analysis of the variables did not change the results. ERCP without manometry and crystal analysis approached the cost of empiric cholecystectomy ($5948). Cost of ERCP and manometry but without crystal analysis escalated costs as well ($5189). For cholecystectomy to be the preferred strategy, the total cost would need to be less than $1,314, well below any realistic cost estimate. If the prevalence of microlithiasis/sludge was >80% , then cholecystectomy would be preferred, while ERCP would be preferred with a prevalence of 41%. Monte Carlo simulations found a 54% probability that initial EUS was cost saving in comparison with ERCP, with both strategies dominating immediate cholecystectomy. CONCLUSIONS This cost minimization study identifies EUS as the least costly initial test for the diagnostic evaluation of patients with unexplained pancreatitis with gallbladder in situ. ERCP with manometry and crystal analysis would need to be performed to make costs approach that of EUS.
W1034 Ten-Year Follow Up Study On Acid-Related Disease After H. pylori Eradication Zhou Li-ya, Yan Xiu-e, Lin San-Ren, Ding Shi-gang, Huang Yong-hui, Cui Rong-li, Jin Zhu, Zhang Li, Li Yuan, Meng Ling-mei, Zhang Jing
W1032
Objective To investigate the detected rate on the morbidity of acid-related diseases after Helicobacter pylori eradication in the high incidence region of gastric cancer in China. Methods 1006 adults(age from 35 to 75 years old)were randomly selected in Yantai area, Shandong province where is a high incidence region of gastric cancer area in 1996. Among them five hundreds and fifty two individuals with H. pylori positive were randomly divided into treatment group(n=276) and placebo group (n=276). Treatment group received triple therapy (omeprazol, amoxyciliin and clarithromycin) for one week.The placebo group was served as control. One month later, Hp status was reassessed by 13C-UBT. Eradication rate of Hp in the T group was 89%.Follow-up study was carried out with endoscopy in the 2nd,5th, 8th and 10th year, respectively. The endoscopic results were compared. Results (1)At 1,5,8 and 10 years after eradication , the response rates of subjects were 89.13 %, 83.11 % ,80.38% and 75.90% respectively. (2)At 1, 5, 8 and 10 year ,the morbidity rates of RE were 1.6% and 0.4%,7.2% and 5.9%,16.1% and 13.6%,27.6% and 21.2% in T and P group.There was no difference between two groups. But RE detection rate increased yearly in both groups. There were no significantl differences about detected rate of peptic ulcer between the two groups. At 1 ,5 years after eradication GU's detection rate was significantly lower than P group.During the follow-up , new incidence of gastric ulcer was lower in T group than P group at 1, 5 and 8 year, but no diffenrence at 10 year.There were significant differences between the two groups. At one, five and eight years after eradication, DU's detection rate in T group was significantly lower than P group ,but no significant difference at ten years . During the follow up, new incidence of DU in T group was significantly less than P group. Recurrent incidence in T group were significantly less than the P group at one, five and eight years, but no significant difference at five years. (3)In Hp-positive group, Hp infection state continued unchanged accouted for 46.18%.In Hp-negative group, Hp infection state continued unchanged accouted for 48.68%.(4) There was no significant difference in patients'age of RE. Male was more than female. Conclusion: The detected rate of peptic ulcer have been decreasing after Hp eradication, during the ten-year follow up, the H. pylori infection status was kept stable in 50% patients. There was no obvious effect on detected rate of reflux esophagitis after H. pylori eradication. The morbidity of reflux esophagitis has been increasing year by year and higher in male than female.
Economic Analysis and Outcomes of 10-Day Sequential Therapy Compared to 10-Day Triple Therapy for Helicobacter pylori (H Pylori) Eradication Nimish Vakil, Angelo Zullo, Chiara Ricci, Dino Vaira We previously reported the results of a randomized, controlled trial of H pylori eradication comparing 10 day triple with sequential therapy. Following the trial, all failures received salvage therapies followed by a repeat UBT until a cure was achieved. We report the costs and outcomes of each treatment strategy that includes the cost of treating failures. Aim: To determine the cost of a strategy using 10-day triple therapy for the eradication of H pylori compared to 10-day sequential therapy. Methods: 295 patients enrolled in a randomized controlled trial of H pylori eradication were studied. All failures received salvage therapies (depending on the initial therapy received) and then a UBT after 4 weeks to confirm eradication. If treatment was unsuccessful, further salvage therapies were administered until the patient was cured or no further therapy was possible. Costs were based on actual medication costs and the real cost of UBT (Sequential therapy=66.92 euros, triple therapy= 90.3 euros, 10 day levofloxacin triple therapy=92.8 euros, 10 day rifabutin triple=91.82 euros, 14 day quadruple therapy=108.30, UBT=48euros). 253 UBTs were done in the sequential and 326 in the standard treatment group. Results: 295 patients participated in a randomized controlled trial that compared 10 day triple with 10 day sequential therapy. 116/149 patients had successful eradication (UBT at 4 and 8 weeks) in the triple therapy group and 133/146 had successful eradication in the sequential therapy group with 6 lost to follow-up. Patients who failed therapy received a salvage regimen and their eradication status was determined by UBT 4 weeks after completion of therapy. 10 patients in the sequential treatment received levofloxacin triple therapy of whom 5 had successful eradication and 1 failure went on to rifabutin triple therapy with a cure. Three patients were lost to follow-up. In the triple therapy, 23 of 30 patients with failed eradication received levofloxacin triple therapy with successful eradication in 20. One patient received sequential therapy with a cure. Three patients were lost to follow-up and 3 patients are awaiting evaluation after quadruple therapy. The total cost of a triple based strategy (31,582 euros) was significantly greater than the total cost of sequential therapy (22,656) and the average cost of treatment was 226 euros/cure compared to 161 euros/cure with sequential therapy (p<0.05 for both). Conclusions: Ten day sequential therapy is more effective and less expensive than ten day triple therapy. The medication costs are lower, the success rate is higher and the cost/cure eventually achieved is substantially better with sequential therapy
W1035 Very High Rate of Misdiagnosis of Celiac Disease in Practice Maria Ines Pinto Sanchez, Edgardo Smecuol, Roberto M. Mazure, Emilia Sugai, Horacio Vazquez, Sonia Niveloni, Eduardo Mauriño, Julio C. Bai
W1033
Background: Diagnosis of celiac disease (CD) is based on intestinal biopsy showing the presence of enteropathy and a congruent positive specific serology. However, the performance of these tools in clinical practice remains unknown and potential pitfalls may result in diagnostic misinterpretation. Aim: Our goal was to analyze the diagnostic performance of CD-related serology and the histological assessment of duodenal biopsies performed in practice. Material and methods: From September 2003 to October 2006, 54 consecutive patients referred to our tertiary center for a second opinion were enrolled in this retrospective study if biopsy slides used for diagnosis by external pathologists were available as well as the CD-related serology performed at diagnosis in both, the general labs and our specialized lab. An expert pathologist performed reviewed the original slides blinded to the former diagnosis. We considered as diagnostic gold standard of CD the serology and the histology assessment (Marsh's type II or greater enteropathy) performed in our referral center. Response to a gluten-free diet was considered in cases were serology and histology did not agree. Cases where the expert pathologist was not able to arrive at a diagnosis were excluded. According to original reports, 43 patients (79.6%) had been categorized with CD and 11 (20.4%) as not having the disorder. Results: According to the gold standard criteria, only 22 patients (40.7%) were diagnosed with CD and 32 (59.3%) had not CD. Overall, 24
Seasonal Variation in the Incidence of Eosinophilic Esophagitis Over 30 Years : A Population Based Study Ganapathy A. Prasad, Thomas C. Smyrk, Cathy Schleck, Alan R. Zinsmeister, G. Richard Locke, Jeffrey A. Alexander, Nicholas J. Talley Background and Aims: Eosinophilic esophagitis (EE) is an increasingly recognized disease with unclear etiology. Seasonal variation in the time of diagnosis of EE may support the role of inhaled allergens. Data on seasonal variation in diagnosis are limited. We aimed to study the seasonal variation in the diagnosis of EE in a population based setting over the last thirty years in Olmsted County, MN. Methods: All cases of EE diagnosed between 1976 and 2007 were identified using the Rochester Epidemiology Project resources. All esophageal biopsies with evidence of any eosinophilic infiltration were re-reviewed by a single pathologist using a consistent histologic standard (>15 eos/hpf). Demographic and clinical data was extracted using medical records as well as prospectively using a telephone questionnaire. The date of the first esophageal biopsy showing >15 eosinophils/hpf was taken as the date of diagnosis of EE. Statistical analysis was performed using the Rayleigh test of circular
A-619
AGA Abstracts
AGA Abstracts
W1031
Cost Minimization Analysis Comparing Diagnostic Strategies in Unexplained Pancreatitis Charles M. Wilcox, Meredith Kilgore BACKGROUND: Both ERCP and EUS are commonly performed in the evaluation of idiopathic pancreatitis. However, comparative trials of these modalities are lacking and thus the ideal endoscopic diagnostic strategy to evaluate idiopathic pancreatitis remains unknown. METHODS: A decision analysis model of patients with two attacks of unexplained pancreatitis with gallbladder in situ was constructed using Treeage® software. We analyzed cost and overall diagnostic ability of three strategies: endoscopic ultrasonography (EUS), endoscopic retrograde cholangiopancreatography with manometry and bile aspiration (ERCP), and laparoscopic cholecystectomy. The probability of causes of pancreatitis and costs were determined from the medical literature and Medicare fee schedules, respectively. One and two way sensitivity analyses were conducted to identify variables with the greatest effects on model outputs and a probabilistic sensitivity analysis was conducted using Monte Carlo simulation. RESULTS Using the base case analysis, initial EUS was the preferred initial modality for the diagnosis. The expected cost for initial EUS was $4,469 compared with $4,615 for ERCP and $6,268 for laparoscopic cholecystectomy. The findings were robust across a wide probability of microlithiasis / sludge. One and two-way sensitivity analysis of the variables did not change the results. ERCP without manometry and crystal analysis approached the cost of empiric cholecystectomy ($5948). Cost of ERCP and manometry but without crystal analysis escalated costs as well ($5189). For cholecystectomy to be the preferred strategy, the total cost would need to be less than $1,314, well below any realistic cost estimate. If the prevalence of microlithiasis/sludge was >80% , then cholecystectomy would be preferred, while ERCP would be preferred with a prevalence of 41%. Monte Carlo simulations found a 54% probability that initial EUS was cost saving in comparison with ERCP, with both strategies dominating immediate cholecystectomy. CONCLUSIONS This cost minimization study identifies EUS as the least costly initial test for the diagnostic evaluation of patients with unexplained pancreatitis with gallbladder in situ. ERCP with manometry and crystal analysis would need to be performed to make costs approach that of EUS.
W1034 Ten-Year Follow Up Study On Acid-Related Disease After H. pylori Eradication Zhou Li-ya, Yan Xiu-e, Lin San-Ren, Ding Shi-gang, Huang Yong-hui, Cui Rong-li, Jin Zhu, Zhang Li, Li Yuan, Meng Ling-mei, Zhang Jing
W1032
Objective To investigate the detected rate on the morbidity of acid-related diseases after Helicobacter pylori eradication in the high incidence region of gastric cancer in China. Methods 1006 adults(age from 35 to 75 years old)were randomly selected in Yantai area, Shandong province where is a high incidence region of gastric cancer area in 1996. Among them five hundreds and fifty two individuals with H. pylori positive were randomly divided into treatment group(n=276) and placebo group (n=276). Treatment group received triple therapy (omeprazol, amoxyciliin and clarithromycin) for one week.The placebo group was served as control. One month later, Hp status was reassessed by 13C-UBT. Eradication rate of Hp in the T group was 89%.Follow-up study was carried out with endoscopy in the 2nd,5th, 8th and 10th year, respectively. The endoscopic results were compared. Results (1)At 1,5,8 and 10 years after eradication , the response rates of subjects were 89.13 %, 83.11 % ,80.38% and 75.90% respectively. (2)At 1, 5, 8 and 10 year ,the morbidity rates of RE were 1.6% and 0.4%,7.2% and 5.9%,16.1% and 13.6%,27.6% and 21.2% in T and P group.There was no difference between two groups. But RE detection rate increased yearly in both groups. There were no significantl differences about detected rate of peptic ulcer between the two groups. At 1 ,5 years after eradication GU's detection rate was significantly lower than P group.During the follow-up , new incidence of gastric ulcer was lower in T group than P group at 1, 5 and 8 year, but no diffenrence at 10 year.There were significant differences between the two groups. At one, five and eight years after eradication, DU's detection rate in T group was significantly lower than P group ,but no significant difference at ten years . During the follow up, new incidence of DU in T group was significantly less than P group. Recurrent incidence in T group were significantly less than the P group at one, five and eight years, but no significant difference at five years. (3)In Hp-positive group, Hp infection state continued unchanged accouted for 46.18%.In Hp-negative group, Hp infection state continued unchanged accouted for 48.68%.(4) There was no significant difference in patients'age of RE. Male was more than female. Conclusion: The detected rate of peptic ulcer have been decreasing after Hp eradication, during the ten-year follow up, the H. pylori infection status was kept stable in 50% patients. There was no obvious effect on detected rate of reflux esophagitis after H. pylori eradication. The morbidity of reflux esophagitis has been increasing year by year and higher in male than female.
Economic Analysis and Outcomes of 10-Day Sequential Therapy Compared to 10-Day Triple Therapy for Helicobacter pylori (H Pylori) Eradication Nimish Vakil, Angelo Zullo, Chiara Ricci, Dino Vaira We previously reported the results of a randomized, controlled trial of H pylori eradication comparing 10 day triple with sequential therapy. Following the trial, all failures received salvage therapies followed by a repeat UBT until a cure was achieved. We report the costs and outcomes of each treatment strategy that includes the cost of treating failures. Aim: To determine the cost of a strategy using 10-day triple therapy for the eradication of H pylori compared to 10-day sequential therapy. Methods: 295 patients enrolled in a randomized controlled trial of H pylori eradication were studied. All failures received salvage therapies (depending on the initial therapy received) and then a UBT after 4 weeks to confirm eradication. If treatment was unsuccessful, further salvage therapies were administered until the patient was cured or no further therapy was possible. Costs were based on actual medication costs and the real cost of UBT (Sequential therapy=66.92 euros, triple therapy= 90.3 euros, 10 day levofloxacin triple therapy=92.8 euros, 10 day rifabutin triple=91.82 euros, 14 day quadruple therapy=108.30, UBT=48euros). 253 UBTs were done in the sequential and 326 in the standard treatment group. Results: 295 patients participated in a randomized controlled trial that compared 10 day triple with 10 day sequential therapy. 116/149 patients had successful eradication (UBT at 4 and 8 weeks) in the triple therapy group and 133/146 had successful eradication in the sequential therapy group with 6 lost to follow-up. Patients who failed therapy received a salvage regimen and their eradication status was determined by UBT 4 weeks after completion of therapy. 10 patients in the sequential treatment received levofloxacin triple therapy of whom 5 had successful eradication and 1 failure went on to rifabutin triple therapy with a cure. Three patients were lost to follow-up. In the triple therapy, 23 of 30 patients with failed eradication received levofloxacin triple therapy with successful eradication in 20. One patient received sequential therapy with a cure. Three patients were lost to follow-up and 3 patients are awaiting evaluation after quadruple therapy. The total cost of a triple based strategy (31,582 euros) was significantly greater than the total cost of sequential therapy (22,656) and the average cost of treatment was 226 euros/cure compared to 161 euros/cure with sequential therapy (p<0.05 for both). Conclusions: Ten day sequential therapy is more effective and less expensive than ten day triple therapy. The medication costs are lower, the success rate is higher and the cost/cure eventually achieved is substantially better with sequential therapy
W1035 Very High Rate of Misdiagnosis of Celiac Disease in Practice Maria Ines Pinto Sanchez, Edgardo Smecuol, Roberto M. Mazure, Emilia Sugai, Horacio Vazquez, Sonia Niveloni, Eduardo Mauriño, Julio C. Bai
W1033
Background: Diagnosis of celiac disease (CD) is based on intestinal biopsy showing the presence of enteropathy and a congruent positive specific serology. However, the performance of these tools in clinical practice remains unknown and potential pitfalls may result in diagnostic misinterpretation. Aim: Our goal was to analyze the diagnostic performance of CD-related serology and the histological assessment of duodenal biopsies performed in practice. Material and methods: From September 2003 to October 2006, 54 consecutive patients referred to our tertiary center for a second opinion were enrolled in this retrospective study if biopsy slides used for diagnosis by external pathologists were available as well as the CD-related serology performed at diagnosis in both, the general labs and our specialized lab. An expert pathologist performed reviewed the original slides blinded to the former diagnosis. We considered as diagnostic gold standard of CD the serology and the histology assessment (Marsh's type II or greater enteropathy) performed in our referral center. Response to a gluten-free diet was considered in cases were serology and histology did not agree. Cases where the expert pathologist was not able to arrive at a diagnosis were excluded. According to original reports, 43 patients (79.6%) had been categorized with CD and 11 (20.4%) as not having the disorder. Results: According to the gold standard criteria, only 22 patients (40.7%) were diagnosed with CD and 32 (59.3%) had not CD. Overall, 24
Seasonal Variation in the Incidence of Eosinophilic Esophagitis Over 30 Years : A Population Based Study Ganapathy A. Prasad, Thomas C. Smyrk, Cathy Schleck, Alan R. Zinsmeister, G. Richard Locke, Jeffrey A. Alexander, Nicholas J. Talley Background and Aims: Eosinophilic esophagitis (EE) is an increasingly recognized disease with unclear etiology. Seasonal variation in the time of diagnosis of EE may support the role of inhaled allergens. Data on seasonal variation in diagnosis are limited. We aimed to study the seasonal variation in the diagnosis of EE in a population based setting over the last thirty years in Olmsted County, MN. Methods: All cases of EE diagnosed between 1976 and 2007 were identified using the Rochester Epidemiology Project resources. All esophageal biopsies with evidence of any eosinophilic infiltration were re-reviewed by a single pathologist using a consistent histologic standard (>15 eos/hpf). Demographic and clinical data was extracted using medical records as well as prospectively using a telephone questionnaire. The date of the first esophageal biopsy showing >15 eosinophils/hpf was taken as the date of diagnosis of EE. Statistical analysis was performed using the Rayleigh test of circular
A-619
AGA Abstracts
AGA Abstracts
W1031