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What is the Diagnostic Utility of an Abdominal CT Scan in the Hospitalized Medical Patient With Nonspecific Abdominal Pain?
the transverse colon, 71.4% in the descending colon, and 53.3% in the cecum. By lesion size in 271 adenomas, the detection rate of CTC was 94 of 158 (59.5%) for adenomas 2 to 5 mm in size, 55 of 61 (90.2%) for those 6 to 9 mm in size, and 44 of 52 (84.6%) for those at least 10 mm in size. Among adenomas measuring 6mm or more and pathologically considered precancerous, the detection rate of CTC was 88.4%. Conclusions: CTC is useful for detection of colon tumors, including cancers and including adenomas over 6 mm in size. This modality represents effective screening for colon cancer.
Mo1133
Background and study aims Colonoscopy may be an uncomfortable examination in unsedated patients. Knowing the position of the endoscope may be important in reducing both the patient's pain and time to reach the ceacam. The recently introduced Magnetic Imaging System (MEI) allows a continuous real-time view of the endoscope during colonoscopy, while traditional fluoroscopy is only used on-demand and has the disadvantage of radiation hazard. This study compares MEI to standard fluoroscopy in unsedated colonoscopies performed by experienced and inexperienced endoscopists. Patients and methods Eight hundred and ten out-patients referred for colonoscopy were randomized to examination with the aid of either MEI or fluoroscopy. The primary end point was perceived patient pain. Secondary outcome measures included caecum intubation time, caecum intubation rate, need for assistance from another colleague and use of analgesics/sedation. Results There was a trend towards less severe pain in the MEI group compared to the fluoroscopy group (12.6% versus 16.7%, p=0.15%). Time to reach the caecum was similar in the two study groups. The caecum intubation rate was significantly higher for inexperienced endoscopists in the MEI group (77.8%) compared to the fluoroscopy group (56%), p=0.02, but not for experienced physicians (94.0% for MEI and 96.0% for fluoroscopy, p=0.9). Inexperienced endoscopists had less need for assistance from a senior colleague when using MEI (18.5%) compared to fluoroscopy (40.0%), p=0.02. Conclusion Inexperienced endoscopists improved colonoscopy performance with a higher caecum intubation rate when they used the MEI compared to fluoroscopy, but experienced did not. The MEI may be a better tool than fluoroscopy in colonoscopy centers which are educating new endoscopists. There was a trend towards less perceived patient pain in the MEI group, but this did not reach statistically significant difference.
Mo1131 What is the Diagnostic Utility of an Abdominal CT Scan in the Hospitalized Medical Patient With Nonspecific Abdominal Pain? Imran Sheikh, Maya Merheb, Amy Soloman, Wen Zhang, Catherine Curley, Kevin D. Mullen Background: In 2008 abdominal pain was the most common non-injury ER reason for presentation and the use of advanced medical imaging for such presentations increased 123%. Abdominal pain is a common indication for hospitalization and often patients have non-specific abdominal pain (NSAP), defined as that lasting under 7 days and for which there is no diagnosis after examination and baseline investigations. Objective: To determine the diagnostic utility of the abdominal CT scan in the hospitalized medical patient with NSAP. Methods: All adult medicine inpatients with an ICD-9 primary or admitting diagnosis of ‘abdominal pain’ between 7/1/09 to 6/30/10 (n=90) were reviewed to determine location of admission generation, whether a CT was ordered, which department initiated the order and whether it was diagnostic. We further assessed whether associated factors on presentation led to either a CT scan or a positive CT scan. Results: For the 85 patients included in our study, 94% were admitted from the Emergency Department/ Clinical Decision Unit (ED/ CDU) area and 6% from outpatient clinics (OPC) (p<0.0001). 61% received an abdominal CT; 79% of scans were ordered by the ED/ CDU, none were ordered by the OPC, 17% were ordered by the department of Medicine and 4% were ordered by the department of Family Practice (p<0.0001). Of the 52 patients receiving a CT, 14% were diagnostic. No significant relationship was observed between age, race, gender, past medical history, insurance status, fever, white cell count, pain duration, nausea, emesis, unintentional weight loss, respiratory rate, lab abnormalities, rectal bleeding and getting a CT scan with or without positive findings. Of the 7 patients with positive CT findings the maximum subjective pain score reported by 4 patients was 8/10, pain scores of 7, 9 and 10 were reported once each (p=0.02). Patients presenting with epigastric or left upper quadrant pain were less likely to receive a CT scan (p=0.01, p=0.029 respectively), those with associated diarrhea or normal SBP were also less likely to get a CT scan (p=0.025, p=0.031). Those with associated constipation were more likely to have a CT scan with positive findings (p=0.03). Whereas no significant association was noted between receiving a CT scan and length of hospital stay (LOS), a significant association between positive CT findings and LOS was noted, with 43% of patients with positive findings staying 3 days (p=0.03). Conclusions: The diagnostic utility of an abdominal CT in patients with NSAP is low and it's use is best determined on a case by case basis based on clinical judgment until more formal guidelines are developed. Such guidelines would help prevent unnecessary radiation exposure and spiraling health care costs.
Mo1134 Computed Tomographic Colonography Increases Colorectal Cancer Screening Compliance Lindsay E. Jones, Brooks D. Cash, Kathryn Stamps Purpose: Computed Tomographic Colonography (CTC) has been endorsed as an accurate, minimally invasive and well tolerated screening modality for colorectal cancer (CRC). Currently, CTC is not included as one of the Healthcare Effectiveness Data and Information (HEDIS) criteria for CRC screening tests. As a result, institutions providing CTC as a CRC screening test may underestimate HEDIS CRC screening compliance despite provision of a widely recommended and covered CRC screening test. The purpose of this analysis was to examine the effect of CTC on CRC screening HEDIS benchmarks at regional military treatment facilities (MTF). Methods: Data was obtained by querying procedure codes from all patients aged 50 and over who underwent CTC at the National Naval Medical Center Bethesda (NNMC) and Naval Medical Center San Diego (NMCSD). The data was cross-referenced with monthly updates of action reports including demographics, type, and date of previous CRC screening for patients enrolled in these facilities. Actual temporal trend compliance percentages and enrollee counts for April 2009 - April 2010 were extracted from data graphs showing HEDIS-eligible CRC screening. CTC data are only available from monthly updated action reports. Data were maintained for two months of CRC screening action reports to identify CTC-compliant patients and estimated the percent of patients screened each month with CTCs at NNMC and NMCSD. Using this percentage and the number of enrollees each month the percentage of patients that would be considered compliant assuming HEDIS inclusion of CTC was estimated for April 2009-April 2010. Patients compliant with CRC screening who underwent both CTC and another HEDIS-eligible CRC screening test were not counted in the CTC monthly compliance estimate, avoiding duplication and overestimation. Results: During 2009 - 2010, 1,449 enrollees at NNMC and 187 enrollees at NMCSD underwent CTC. At NNMC, in the months of February, March and April 2010, HEDIS compliance was below the HEDIS 90th percentile (69.6%) at 69%, 68.4%, and 68.1%, respectively. When patients who had undergone only CTC were included, CRC screening compliance increased by a range of 4.7% - 5.7% to 75.3%, 74.6%, and 74.3%, well over the HEDIS 90th percentile. At NMCSD, the addition of CTC as a HEDIS-eligible test had little impact on compliance. The percentage of MTF enrolled compliant patients remained slightly above the HEDIS 75th percentile (65%) in February - April 2010. Conclusion: Inclusion of CTC within the HEDIS CRC screening benchmarks can meaningfully increase CRC screening compliance estimates. Exclusion of CTC can penalize sites that perform CTC for CRC screening.
Mo1132 Comparison of Safety and Efficacy of ERCP in Prone and Left Lateral Decubitus Positions Mashal J. Batheja, Michael D. Crowell, Ananya Das, Rodney A. Engel, M. Edwyn Harrison Background: ERCP is typically performed with the patient in the prone position, but can be challenging under conditions such as significant ascites, advanced pregnancy, and indwelling percutaneous catheters. ERCP in the supine position has been shown to be an acceptable alternative when prone positioning is challenging. There are currently no studies specifically evaluating another alternative which is occasionally used by endoscopists, the left lateral decubitus (LLD) position. Objective: Compare efficacy and safety of ERCP in the prone versus left lateral decubitus position. Methods: Consecutive electronic medical records of ERCPs completed by one therapeutic endoscopist from August 2009 to October 2010 at a tertiary academic center were evaluated. Studies were included if patients were older than 18 years with a native papilla for biliary indications. We sequentially compared records of patients who had ERCP in LLD versus prone position. The primary outcome measures were bile duct cannulation success rate, time to initial ampullary localization, time to deep bile duct cannulation, and procedural complications. Data are presented as mean (SD) or median (IRQ; interquartile range). Results: ERCP was completed in 59 patients (39 prone, 20 LLD). Groups were not significantly different in gender, age, procedural respiratory or cardiac complications, and post-procedural complications. The cannulation success rate was 100% in the prone position and 90% in LLD (P=0.11). Median (IRQ) time from scope insertion to initial ampullary localization was 90 (70-110) seconds in prone position and 100 (80118) seconds in LLD (P=0.16). Median time from initial ampullary impaction to deep bile duct cannulation was 140 (45-350) seconds in the prone position and 165 (55-418) seconds in LLD (P=0.54). Conclusion: In patients undergoing ERCP in LLD and prone positions, there was no significant difference in bile duct cannulation rate, time to initial ampullary localization, or time to deep bile duct intubation according to position. Also, there was no significant difference in rates of procedural complications. ERCP in the left lateral decubitus position should be attempted when the standard prone position is deemed to be technically challenging.
S-565
AGA Abstracts
AGA Abstracts
Magnetic Endoscopic Imaging Versus Fluoroscopy in a Routine Colonoscopy Setting: A Randomized Controlled Trial Oeyvind Holme, Ole Hoeie, Jon Matre, Asbjoern Stallemo, Kjetil Garborg, Geir Hoff, Michael Bretthauer
Mo1133
Background and study aims Colonoscopy may be an uncomfortable examination in unsedated patients. Knowing the position of the endoscope may be important in reducing both the patient's pain and time to reach the ceacam. The recently introduced Magnetic Imaging System (MEI) allows a continuous real-time view of the endoscope during colonoscopy, while traditional fluoroscopy is only used on-demand and has the disadvantage of radiation hazard. This study compares MEI to standard fluoroscopy in unsedated colonoscopies performed by experienced and inexperienced endoscopists. Patients and methods Eight hundred and ten out-patients referred for colonoscopy were randomized to examination with the aid of either MEI or fluoroscopy. The primary end point was perceived patient pain. Secondary outcome measures included caecum intubation time, caecum intubation rate, need for assistance from another colleague and use of analgesics/sedation. Results There was a trend towards less severe pain in the MEI group compared to the fluoroscopy group (12.6% versus 16.7%, p=0.15%). Time to reach the caecum was similar in the two study groups. The caecum intubation rate was significantly higher for inexperienced endoscopists in the MEI group (77.8%) compared to the fluoroscopy group (56%), p=0.02, but not for experienced physicians (94.0% for MEI and 96.0% for fluoroscopy, p=0.9). Inexperienced endoscopists had less need for assistance from a senior colleague when using MEI (18.5%) compared to fluoroscopy (40.0%), p=0.02. Conclusion Inexperienced endoscopists improved colonoscopy performance with a higher caecum intubation rate when they used the MEI compared to fluoroscopy, but experienced did not. The MEI may be a better tool than fluoroscopy in colonoscopy centers which are educating new endoscopists. There was a trend towards less perceived patient pain in the MEI group, but this did not reach statistically significant difference.
Mo1131 What is the Diagnostic Utility of an Abdominal CT Scan in the Hospitalized Medical Patient With Nonspecific Abdominal Pain? Imran Sheikh, Maya Merheb, Amy Soloman, Wen Zhang, Catherine Curley, Kevin D. Mullen Background: In 2008 abdominal pain was the most common non-injury ER reason for presentation and the use of advanced medical imaging for such presentations increased 123%. Abdominal pain is a common indication for hospitalization and often patients have non-specific abdominal pain (NSAP), defined as that lasting under 7 days and for which there is no diagnosis after examination and baseline investigations. Objective: To determine the diagnostic utility of the abdominal CT scan in the hospitalized medical patient with NSAP. Methods: All adult medicine inpatients with an ICD-9 primary or admitting diagnosis of ‘abdominal pain’ between 7/1/09 to 6/30/10 (n=90) were reviewed to determine location of admission generation, whether a CT was ordered, which department initiated the order and whether it was diagnostic. We further assessed whether associated factors on presentation led to either a CT scan or a positive CT scan. Results: For the 85 patients included in our study, 94% were admitted from the Emergency Department/ Clinical Decision Unit (ED/ CDU) area and 6% from outpatient clinics (OPC) (p<0.0001). 61% received an abdominal CT; 79% of scans were ordered by the ED/ CDU, none were ordered by the OPC, 17% were ordered by the department of Medicine and 4% were ordered by the department of Family Practice (p<0.0001). Of the 52 patients receiving a CT, 14% were diagnostic. No significant relationship was observed between age, race, gender, past medical history, insurance status, fever, white cell count, pain duration, nausea, emesis, unintentional weight loss, respiratory rate, lab abnormalities, rectal bleeding and getting a CT scan with or without positive findings. Of the 7 patients with positive CT findings the maximum subjective pain score reported by 4 patients was 8/10, pain scores of 7, 9 and 10 were reported once each (p=0.02). Patients presenting with epigastric or left upper quadrant pain were less likely to receive a CT scan (p=0.01, p=0.029 respectively), those with associated diarrhea or normal SBP were also less likely to get a CT scan (p=0.025, p=0.031). Those with associated constipation were more likely to have a CT scan with positive findings (p=0.03). Whereas no significant association was noted between receiving a CT scan and length of hospital stay (LOS), a significant association between positive CT findings and LOS was noted, with 43% of patients with positive findings staying 3 days (p=0.03). Conclusions: The diagnostic utility of an abdominal CT in patients with NSAP is low and it's use is best determined on a case by case basis based on clinical judgment until more formal guidelines are developed. Such guidelines would help prevent unnecessary radiation exposure and spiraling health care costs.
Mo1134 Computed Tomographic Colonography Increases Colorectal Cancer Screening Compliance Lindsay E. Jones, Brooks D. Cash, Kathryn Stamps Purpose: Computed Tomographic Colonography (CTC) has been endorsed as an accurate, minimally invasive and well tolerated screening modality for colorectal cancer (CRC). Currently, CTC is not included as one of the Healthcare Effectiveness Data and Information (HEDIS) criteria for CRC screening tests. As a result, institutions providing CTC as a CRC screening test may underestimate HEDIS CRC screening compliance despite provision of a widely recommended and covered CRC screening test. The purpose of this analysis was to examine the effect of CTC on CRC screening HEDIS benchmarks at regional military treatment facilities (MTF). Methods: Data was obtained by querying procedure codes from all patients aged 50 and over who underwent CTC at the National Naval Medical Center Bethesda (NNMC) and Naval Medical Center San Diego (NMCSD). The data was cross-referenced with monthly updates of action reports including demographics, type, and date of previous CRC screening for patients enrolled in these facilities. Actual temporal trend compliance percentages and enrollee counts for April 2009 - April 2010 were extracted from data graphs showing HEDIS-eligible CRC screening. CTC data are only available from monthly updated action reports. Data were maintained for two months of CRC screening action reports to identify CTC-compliant patients and estimated the percent of patients screened each month with CTCs at NNMC and NMCSD. Using this percentage and the number of enrollees each month the percentage of patients that would be considered compliant assuming HEDIS inclusion of CTC was estimated for April 2009-April 2010. Patients compliant with CRC screening who underwent both CTC and another HEDIS-eligible CRC screening test were not counted in the CTC monthly compliance estimate, avoiding duplication and overestimation. Results: During 2009 - 2010, 1,449 enrollees at NNMC and 187 enrollees at NMCSD underwent CTC. At NNMC, in the months of February, March and April 2010, HEDIS compliance was below the HEDIS 90th percentile (69.6%) at 69%, 68.4%, and 68.1%, respectively. When patients who had undergone only CTC were included, CRC screening compliance increased by a range of 4.7% - 5.7% to 75.3%, 74.6%, and 74.3%, well over the HEDIS 90th percentile. At NMCSD, the addition of CTC as a HEDIS-eligible test had little impact on compliance. The percentage of MTF enrolled compliant patients remained slightly above the HEDIS 75th percentile (65%) in February - April 2010. Conclusion: Inclusion of CTC within the HEDIS CRC screening benchmarks can meaningfully increase CRC screening compliance estimates. Exclusion of CTC can penalize sites that perform CTC for CRC screening.
Mo1132 Comparison of Safety and Efficacy of ERCP in Prone and Left Lateral Decubitus Positions Mashal J. Batheja, Michael D. Crowell, Ananya Das, Rodney A. Engel, M. Edwyn Harrison Background: ERCP is typically performed with the patient in the prone position, but can be challenging under conditions such as significant ascites, advanced pregnancy, and indwelling percutaneous catheters. ERCP in the supine position has been shown to be an acceptable alternative when prone positioning is challenging. There are currently no studies specifically evaluating another alternative which is occasionally used by endoscopists, the left lateral decubitus (LLD) position. Objective: Compare efficacy and safety of ERCP in the prone versus left lateral decubitus position. Methods: Consecutive electronic medical records of ERCPs completed by one therapeutic endoscopist from August 2009 to October 2010 at a tertiary academic center were evaluated. Studies were included if patients were older than 18 years with a native papilla for biliary indications. We sequentially compared records of patients who had ERCP in LLD versus prone position. The primary outcome measures were bile duct cannulation success rate, time to initial ampullary localization, time to deep bile duct cannulation, and procedural complications. Data are presented as mean (SD) or median (IRQ; interquartile range). Results: ERCP was completed in 59 patients (39 prone, 20 LLD). Groups were not significantly different in gender, age, procedural respiratory or cardiac complications, and post-procedural complications. The cannulation success rate was 100% in the prone position and 90% in LLD (P=0.11). Median (IRQ) time from scope insertion to initial ampullary localization was 90 (70-110) seconds in prone position and 100 (80118) seconds in LLD (P=0.16). Median time from initial ampullary impaction to deep bile duct cannulation was 140 (45-350) seconds in the prone position and 165 (55-418) seconds in LLD (P=0.54). Conclusion: In patients undergoing ERCP in LLD and prone positions, there was no significant difference in bile duct cannulation rate, time to initial ampullary localization, or time to deep bile duct intubation according to position. Also, there was no significant difference in rates of procedural complications. ERCP in the left lateral decubitus position should be attempted when the standard prone position is deemed to be technically challenging.
S-565
AGA Abstracts
AGA Abstracts
Magnetic Endoscopic Imaging Versus Fluoroscopy in a Routine Colonoscopy Setting: A Randomized Controlled Trial Oeyvind Holme, Ole Hoeie, Jon Matre, Asbjoern Stallemo, Kjetil Garborg, Geir Hoff, Michael Bretthauer