Survey of the Impact of COVID-19 on Chronic Liver Disease Patient Care Experiences and Outcomes.

Background: The COVID-19 pandemic has a secondary impact on the health of patients with chronic liver disease (CLD). Our objective was to study this impact on care provision, telemedicine, and health behaviours in CLD patients. Methods: CLD patients of an urban gastroenterology clinic who attended a telemedicine appointment between March 17, 2020 and September 17, 2020, completed an online survey on care delays, health behaviours, and experience with telemedicine. Chart review was conducted in 400 randomly selected patients: 200 charts from during the pandemic were compared to 200 charts the previous year. Data were extracted for clinicodemographic variables, laboratory investigations, and clinical outcomes. Results: Of 399 patients invited to participate, 135 (34%) completed the online survey. Fifty (39%) patients reported 83 care delays due to the COVID-19 pandemic, with the majority (71%) of delays persisting beyond 2 months. Ninety-five (75%) patients were satisfied with telemedicine appointments. There was a longer delay between lab work and appointments in patients seen during the pandemic compared to 2019 (P = 0.01). Compared to the year prior, during the COVID pandemic, there was a similar number of cases of cirrhosis decompensation (n = 26, 13% versus n = 22, 11%) and hospitalization (n = 12, 6% versus n = 5, 3%). Conclusion: The COVID-19 pandemic has led to care delays for CLD outpatients, with most delays on the scale of months. These patient-reported experiences and clinical observations can direct optimization of CLD care as effects from the pandemic evolve.

Existing Bowel Preparation Quality Scales Are Reliable in the Setting of Centralized Endoscopy Reading.

BACKGROUND: Development of bowel preparation products has been based upon colon cleansing rating by a local endoscopist. It is unclear how bowel preparation scales perform when centrally evaluated. AIMS: To evaluate the reliability of bowel preparation quality scales when assessed by central readers. METHODS: Four central readers evaluated 52 videos in triplicate, 2 weeks apart, during the entire endoscopic procedure (insertion/withdrawal of the colonoscope) and exclusively on colonoscope withdrawal using the Boston Bowel Preparation Scale (BBPS), Chicago Bowel Preparation scale, Harefield Cleansing Scale, Ottawa Bowel Preparation Quality Scale (OBPQS), Aronchick score, a visual analogue scale, and additional items proposed in a modified Research and Development/University of California Los Angeles appropriateness process. Reliability was assessed with intraclass correlation coefficients. RESULTS: Intraclass correlation coefficients (95% confidence interval) for inter-rater reliability of the quality scales ranged from 0.51 to 0.65 (consistent with moderate to substantial inter-rater reliability) during the entire procedure. Corresponding intraclass correlation coefficients for intra-rater reliability ranged from 0.69 to 0.77 (consistent with substantial intra-rater reliability). Reliability was highest in the right colon and lowest in the left colon. No differences were observed in reliability when assessed for the procedure overall (insertion/withdrawal) relative to assessment on withdrawal alone. CONCLUSION: All five bowel preparation quality scales had moderate to substantial inter-rater reliability. Panelists considered the Aronchick score too simplistic for clinical trials and recognized that assessment of residual fluid in the Ottawa Bowel Preparation Quality Scale was not amenable to central assessment.

INTERBLEED: Design of an International Study of Risk Factors for Gastrointestinal Bleeding and Cardiovascular Events After Gastrointestinal Bleeding.

Background: Bleeding is the most common adverse event in those with cardiovascular (CV) disease receiving antithrombotic therapy, and it most commonly occurs in the gastrointestinal (GI) tract. Clinicians often dismiss bleeding as an adverse event that is reversible with effective antithrombotic therapy, but bleeding is associated with substantial morbidity and mortality, most likely mediated through an increased risk of CV events. Reducing the burden of bleeding requires knowledge of the potentially modifiable risk factors for bleeding and the potentially modifiable risk factors for adverse outcomes after bleeding. Methods: INTERBLEED is an international, multicentre, 2-component, observational study, with an incident case-control study examining the risk factors for GI bleeding, and a prospective cohort study of risk factors for CV events after GI bleeding. Cases either have CV disease and present to the hospital with GI bleeding or develop GI bleeding during hospitalization. Controls have CV disease, but no history of GI bleeding. We use a questionnaire to obtain detailed information on known and potential risk factors for GI bleeding and for CV events and outcomes after bleeding. We obtain CV and anthropometric measurements, perform functional and cognitive assessments, and follow participants at 3 months and 12 months. Results: As of April 1, 2022, the study is ongoing in 10 countries at 31 centres and has recruited 2407 cases and 1478 controls. Conclusions: Knowledge of risk factors for bleeding, and risk factors for CV events and functional decline after bleeding, will help develop strategies to prevent bleeding and subsequent complications.

Contexte: L'hémorragie est l'effet indésirable le plus fréquent chez les patients atteints de maladies cardiovasculaires (CV) qui reçoivent un traitement antithrombotique, et elle survient le plus souvent dans le tractus gastro-intestinal (GI). Les cliniciens considèrent souvent l'hémorragie comme une simple manifestation indésirable réversible par un traitement antithrombotique efficace, mais une morbidité et une mortalité considérables y sont associées, probablement en raison d'un risque accru d'événements CV. Une réduction du fardeau de l'hémorragie nécessite une connaissance des facteurs de risque potentiellement modifiables tant de l'hémorragie que des événements indésirables qui surviennent après l'hémorragie. Méthodologie: INTERBLEED est une étude internationale, observationnelle et multicentrique à deux volets; le premier volet est une étude cas-témoins incidents visant à examiner les facteurs de risque d'hémorragie GI, alors que le second volet est une étude de cohorte prospective visant à examiner les facteurs de risque d'événements CV après une hémorragie GI. Les cas sont des patients atteints de maladies CV qui consultent les services hospitaliers pour une hémorragie GI ou qui présentent une hémorragie GI en cours d'hospitalisation. Les témoins sont des patients atteints de maladies CV, mais sans antécédents d'hémorragie GI. Un questionnaire est utilisé pour obtenir des renseignements détaillés au sujet de facteurs de risque connus et potentiels d'hémorragie GI et d'événements CV et d'autres résultats de santé après une hémorragie. Des mesures cardiovasculaires et anthropométriques ainsi que des évaluations fonctionnelles et cognitives sont réalisées, et les participants sont revus après trois mois et 12 mois. Résultats: En date du 1er avril 2022, l'étude est en cours dans 10 pays et 31 établissements de santé; 2 407 cas et 1 478 témoins ont été recrutés. Conclusions: La connaissance des facteurs de risque d'hémorragie, ainsi que des facteurs de risque d'événements CV et de déclin fonctionnel à la suite d'une hémorragie, aidera à mettre en place des stratégies pour prévenir les hémorragies et les complications qui peuvent en découler.

Impact of Telehealth on Medication Adherence in Chronic Gastrointestinal Diseases.

Background: With the COVID-19 pandemic, the demand and availability of telehealth in outpatient care has had exponential growth. Although use of telehealth has been studied and validated for various medical specialties, relatively few studies have looked at its role in gastroenterology. Aim: To assess effectiveness of telehealth medicine in gastroenterology by comparing medication adherence rate for patients seen with telehealth and traditional in-person appointment for various gastrointestinal conditions. Methods: Retrospective chart review of patients seen in outpatient gastroenterology clinic was performed to identify patients who were given prescription to fill either through telehealth or in-person appointment. By using provincial pharmacy database, we determined the prescription fill rate. Results: A total of 206 patients were identified who were provided new prescriptions or prescription renewal at their gastroenterology clinic visit. One hundred and three patients were seen through in-person visit during pre-pandemic period, and 103 patients were seen through telehealth appointment during COVID-19 pandemic. The mean age of patients was 49.2 years (55% female). On average, patients had 4.7 previous visits with their gastroenterologists before their visit. IBD management was the most common reason for visits (37.9% and 46.6% in telehealth and in-person groups, respectively). Prescription fill rate for patients seen through telehealth was 92.2% compared to 81.6% for the in-person group (OR: 2.69, 95% CI: 1.12-6.45; P = 0.023). Conclusions: Medication adherence rate for telehealth visits was higher than for in-patient visits. These findings suggest that telehealth can be an effective method of care delivery, especially for patients with chronic gastrointestinal conditions like IBD.

Learning curves in ERCP during advanced endoscopy training: a Canadian multicenter prospective study.

Background and study aims Growing emphasis on quality and patient safety has supported the shift toward competency-based medical education for advanced endoscopy trainees (AETs). In this study, we aimed to examine Canadian AETs learning curves and achievement of competence using an ERCP assessment tool with strong evidence of validity. Methods This prospective study was conducted at five institutions across Canada from 2017-2018. Data on every fifth procedure performed by trainees were collected using the United Kingdom Joint Advisory Joint Advisory Group of Gastrointestinal Endoscopy (JAG) ERCP Direct Observation of Procedural Skills (DOPS) tool, which includes a four-point rating scale for 27 items. Cumulative sum (CUSUM) analysis was used to create learning curves for overall supervision ratings and ERCP DOPS items by plotting scores for procedures performed during training. Results Eleven trainees who were evaluated for 261 procedures comprised our sample. The median number of evaluations by site was 49 (Interquartile range (IQR) 31-76) and by trainee was 15 (IQR 11-45). The overall cannulation rate by trainees was 82 % (241/261), and the native papilla cannulation rate was 78 % (149/191). All trainees achieved competence in the "overall supervision" domain of the ERCP DOPS by the end of their fellowship. Trainees achieved competency in all individual domains, except for tissue sampling and sphincteroplasty. Conclusions Canadian AETs are graduating from fellowship programs with acceptable levels of competence for overall ERCP performance and for the most specific tasks. Learning curves may help identify areas of deficiency that may require supplementary training, such as tissue sampling.

Risks associated with colonoscopy in a population-based colon screening program: an observational cohort study.

BACKGROUND: The risks associated with colonoscopy performed through the British Columbia Colon Screening Program (BCCSP) are not known. We aimed to determine the rate of colonoscopy-related serious adverse events within this program. METHODS: For this prospective observational study, we used the BCCSP database to identify participants 50 to 74 years of age who had a positive result on fecal immunochemical testing (FIT) between Nov. 15, 2013, and Dec. 31, 2017, followed by colonoscopy. Unplanned medical events were recorded at the time of colonoscopy and 14 days later. We reviewed the unplanned events and defined them as serious adverse events if they resulted in death, hospital admission or intervention; we also classified them as probably, possibly or unlikely related to the colonoscopy. The primary outcome was the overall rate of serious adverse events; the secondary outcomes were 14-day post-colonoscopy rates of perforation, bleeding and death. RESULTS: During the study period, a total of 96 192 colonoscopies were performed by 308 physicians at 50 sites. The median age of patients was 62 (10th-90th percentile 52-71) years, and 56% were male. Of these, 78 831 patients were contacted after the colonoscopy. Serious adverse events were deemed to have occurred in 350 colonoscopies (44 per 10 000, 95% confidence interval [CI] 39-50 per 10 000), with a number needed to harm of 225. Of the 332 (94.9%) serious adverse events that were probably or possibly related to colonoscopy, perforation occurred in 6 (95% CI 5-8) per 10 000 colonoscopies, bleeding in 26 (95% CI 22-30) per 10 000 colonoscopies and death in 3 (95% CI 1-10) per 100 000 colonoscopies. INTERPRETATION: The rate of serious adverse events associated with colonoscopy in the BCCSP was in keeping with previous publications and met accepted benchmarks. The findings of this study inform stakeholders of the risks associated with colonoscopy in an FIT-based colon screening program.

Comparing the Real-World Effectiveness of High- Versus Low-Volume Split Colonoscopy Preparations: An Experience Through the British Columbia Colon Cancer Screening Program.

BACKGROUND: The British Columbia Colon Screening Program (BCCSP) is a population-based colon cancer screening program. In December 2018, physicians in Vancouver, Canada agreed to switch from a low-volume split preparation to a high-volume polyethylene glycol preparation after a meta-analysis of studies suggested superiority of the higher volume preparation in achieving adequate bowel cleansing and improving adenoma detection rates. AIMS: To compare the quality of bowel preparation and neoplasia detection rates using a high-volume split preparation (HVSP) versus a low-volume split preparation (LVSP) in patients undergoing colonoscopy in the BCCSP. METHODS: A retrospective review of patients undergoing colonoscopy through the BCCSP at St. Paul's Hospital from July 2017 to November 2018 and December 2018 to November 2019 was conducted. Inclusion criteria included age 50 to 74 and patients undergoing colonoscopy through the BCCSP. Variables collected included patient demographics and bowel preparation quality. Rates of bowel preparation and neoplasia detection were analyzed using chi-squared test. RESULTS: A total of 1453 colonoscopies were included, 877 in the LVSP group and 576 in the HVSP group. No statistically significant difference was noted between rates of inadequate bowel preparation (LVSP 3.6% versus HVSP 2.8%; P = 0.364). Greater rates of excellent (48.4% versus 40.1%; P = 0.002) and optimal (90.1% versus 86.5%; P = 0.041) bowel preparation were achieved with HVSP. The overall adenoma detection rate was similar between the two groups (LVSP 53.1% versus HVSP 54.0%; P = 0.074). LVSP demonstrated higher overall sessile serrated lesion detection rate (9.5% versus 5.6%; P = 0.007). CONCLUSIONS: Compared to LVSP, HVSP was associated with an increase in excellent and optimal bowel preparations, but without an improvement in overall neoplasia detection.

Higher adenoma detection, sessile serrated lesion detection and proximal sessile serrated lesion detection are associated with physician specialty and performance on Direct Observation of Procedural Skills.

OBJECTIVE: Adenoma detection rate (ADR) and sessile serrated lesion detection rate (SSLDR) vary among physicians. We sought to determine physician characteristics associated with ADR and SSLDR in a population-based colon screening programme. DESIGN: Retrospective study of 50-74 year olds with positive faecal immunochemical test and colonoscopy from 15/11/2013 to 31/12/2018. Physician characteristics included: gender, specialty, year and country of medical school graduation, colonoscopy volume and Direct Observation of Procedural Skills (DOPS) performance. Multivariable regression was performed on the following dependent variables: ADR, advanced ADR, proximal and distal ADR, SSLDR, proximal and distal SSLDR. RESULTS: 104 326 colonoscopies were performed by 261 physicians. A higher ADR was associated with gastroenterology (OR for general surgery 0.87, 95% CI 0.80 to 0.95; OR for general/family/internal medicine 0.70, 95% CI 0.55 to 0.88), fewer years since graduation (OR for graduation >2000 10.48, 95% CI 1.30 to 1.69 compared with <1980) and DOPS performance (OR for lowest DOPS performance 0.64, 95% CI 0.50 to 0.82 compared with highest DOPS performance). SSLDR was associated with gastroenterology (OR for general surgery 0.89, 95%, CI 0.81 to 0.97; OR for general/family/internal medicine 0.67, 95% CI 0.49 to 0.92) and DOPS performance (OR for lowest DOPS performance 0.71, 95% CI 0.51 to 0.99 compared with highest DOPS performance). Proximal SSLDR was associated with gastroenterology (OR for general surgery 0.90, 95% CI 0.82 to 0.99; OR for general/family/internal medicine 0.69, 95% CI 0.50 to 0.97) and DOPS performance (OR for lowest DOPS performance 0.68, 95% CI 0.47 to 0.99). CONCLUSION: Higher ADR, SSLDR and proximal SSLDR was associated with gastroenterology specialty and improved performance on DOPS.

Improvement of Endoscopic Reports with Implementation of a Dictation Template.

AIMS: Completeness of procedure reports is an important quality indicator in endoscopy. A dictation template was developed to ensure key elements were included in colonoscopy and esophagogastroduodenoscopy (EGD) reports. Endoscopy reports were reviewed prior to and following implementation of the dictation templates to determine whether report completeness improved. METHODS: Key elements in an endoscopic report were identified from published guidelines and posted at dictation stations. Colonoscopy and EGD reports were reviewed for the nine physicians performing endoscopy at St. Paul's Hospital prior to and following implementation of dictation templates. Dictation completeness was defined as inclusion of all key elements. Dictation completeness and inclusion of individual key elements at the two time points were compared using the t-test and Chi-square test. RESULTS: Reports for 4648 procedures undertaken by nine endoscopists were reviewed for completeness at each time point (2008 and 2014). Colonoscopy report completeness increased from 65.8% to 83.2% (P < 0.001). Items that improved included documentation of consent, endoscope used, complications, withdrawal time and rectal retroflexion. EGD report completeness increased from 72.7% to 77.3% (P < 0.001) with improvement in documentation of consent and complications. Items consistently underreported for colonoscopy and EGD at both time points included: patient age, comorbidities, current medications and patient comfort. CONCLUSION: There was an association between the use of a posted dictation template at dictation stations and the improved completeness of endoscopic reports.

Assessment of Capsule Endoscopy Utilizing Capsocam Plus in Patients With Suspected Small Bowel Disease Including Pilot Study With Remote Access Patients During Pandemic.

BACKGROUND: CapsoCam Plus is a capsule endoscopy (CE) system that utilizes four cameras to capture a panoramic view. This has theoretical advantage over conventional forward-viewing CE with limited field of view. Its ease of administration without requiring any additional equipment during the recording also provides a unique opportunity for patients to self-administer the test. We aimed to evaluate real-life experience using this novel system and to determine feasibility of a remote access program. METHODS: Retrospective chart review was conducted for consecutive adult outpatients who underwent CE using CapsoCam Plus. Patients with significant challenges for in-person procedures were selected for remote access through mail courier services. Gastric transit time, small bowel transit time, completion rate, diagnostic yield and adverse events were compared between remote access versus usual practice. RESULTS: Ninety-four patients (52.1% male) were included, with 28 in remote access program. Most common indication was gastrointestinal bleeding (85.1%). Complete examination was achieved in 87 patients. Five (5.3%) patients' capsule remained in stomach during the recording, while two (2.1%) patients missed capsule retrieval. Median small bowel and gastric transit times were 231.9 (interquartile range [IQR] 169.5-308.2) and 27.6 (IQR 13.8-63.5) minutes, respectively. Diagnostic yield was 23.4%. There was no difference in completion rate or transit times between two groups, but diagnostic yield was higher in remote access group (odds ratio 3.80, 95% confidence interval 1.28-11.31). One patient required elective endoscopic retrieval of capsule. CONCLUSION: CapsoCam Plus can be safely administered remotely with a high degree of success, which may facilitate timely investigations while limiting nonessential physical interactions during pandemic.

Capsule Endoscopy Complements Magnetic Resonance Enterography and Endoscopy in Evaluating Small Bowel Crohn's Disease.

AIMS: Wireless capsule endoscopy (WCE) and magnetic resonance enterography (MRE) are increasingly utilized to evaluate the small bowel (SB) in Crohn's disease (CD). The primary aims were to compare the ability of WCE and MRE to detect SB inflammation in children with newly diagnosed CD, and in the terminal ileum (TI) to compare them to ileo-colonoscopy. Secondary aims were to compare diagnostic accuracy of WCE and MRE and changes in Paris classification after each study. METHODS: Patients (10 to 17 years of age) requiring ileo-colonoscopy for suspected CD were invited to participate. Only patients with endoscopic/histologic evidence of CD underwent MRE and WCE. SB inflammation and extent were documented and comparative analyses performed. RESULTS: Of 38 initially recruited subjects, 20 completed the study. WCE and MRE were similarly sensitive in identifying active TI inflammation (16 [80%] versus 12 [60%]) and any SB inflammation (17 [85%] versus 16 [80%]). However, WCE detected more extensive SB disease than MRE with active inflammation throughout the SB in 15 [75%] versus 1 [5%] patient (P < 0.001). Moreover, WCE was more likely to detect proximal SB disease (jejunum and ileum) compared to MRE (85% versus 50%, P = 0.04). Overall, the Paris classification changed in 65% and 85% of patients following MRE and WCE, respectively. CONCLUSIONS: WCE is as sensitive as MRE for identifying active TI inflammation, but appears more sensitive in identifying more proximal SB inflammation. In the absence of concern regarding stricturing or extra-luminal disease WCE can be considered for the evaluation of suspected SB CD.

Internet-Based Patient Education Prior to Colonoscopy: Prospective, Observational Study of a Single Center's Implementation, with Objective Assessment of Bowel Preparation Quality and Patient Satisfaction.

BACKGROUND: Nonpharmacologic factors, including patient education, affect bowel preparation for colonoscopy. Optimal cleansing increases quality and reduces repeat procedures. This study prospectively analyzes use of an individualized online patient education module in place of traditional patient education. AIMS: To determine the effectiveness of online education for patients, measured by the proportion achieving sufficient bowel preparation. Secondary measures include assessment of patient satisfaction. METHODS: Prospective, single-center, observational study. Adults aged 19 years and over, with an e-mail account, scheduled for nonurgent colonoscopy, with English proficiency (or someone who could translate for them) were recruited. Demographics and objective bowel preparation quality were collected. Patient satisfaction was assessed via survey to assess clarity and usefulness of the module. RESULTS: Nine hundred consecutive patients completed the study. 84.6% of patients achieved adequate bowel preparation as measured by Boston bowel preparation score ≥ 6 and 90.1% scored adequately using Ottawa bowel preparation score ≤7. 94.2% and 92.1% of patients rated the web-education module as 'very useful' and 'very clear', respectively (≥8/10 on respective scales). CONCLUSIONS: Our analysis suggests that internet-based patient education prior to colonoscopy is a viable option and achieves adequate bowel preparation. Preparation quality is comparable to previously published trials. Included patients found the process clear and useful. Pragmatic benefits of a web-based protocol such as time and cost savings were not formally assessed but may contribute to greater satisfaction for endoscopists and patients.

Performance of the Fecal Immunochemical Test in Patients With a Family History of Colorectal Cancer.

OBJECTIVE: To assess the performance of a fecal immunochemical test (FIT) among participants of a population-based colorectal cancer (CRC) screening program with one or more first-degree relatives (FDR) with CRC. METHODS: Asymptomatic 50 to 74 years olds with a FDR diagnosed with CRC, enrolled in a colon screening program completed FIT (two samples, cut-off 20 µg Hemoglobin/gram feces) and underwent colonoscopy. FIT-interval CRCs were identified from the British Columbia cancer registry. Logistic regression analysis was used to identify variables associated with the detection of CRC and high-risk polyps (nonmalignant findings that required a 3-year surveillance colonoscopy) in those patients undergoing FIT and colonoscopy. RESULTS: Of the 1387 participants with a FDR with CRC, 1244 completed FIT with a positivity rate of 10.8%, 52 declined FIT but underwent colonoscopy and 90 declined screening. Seven CRCs were identified: six in patients with a positive FIT, one in a patient who only had colonoscopy. No CRCs were found in patients with a negative FIT. The positive and negative predictive values of FIT in the detection of CRC were 4.8% and 100%, respectively. On multivariate logistic regression, positive FIT, and not type of family history, was the only variable associated with detection of CRC or high-risk polyps. At 2-year follow-up, there was no FIT interval cancer detected in the study cohort. CONCLUSION: FIT is more strongly associated with high-risk findings on colonoscopy than type of family history. FIT may be an alternative screening strategy to colonoscopy in individuals with a single FDR with CRC.

Validation of the St. Paul's Endoscopy Comfort Scale (SPECS) for Colonoscopy.

AIMS: Patient comfort during colonoscopy is an important measure of quality, which can improve patient satisfaction and compliance with future procedures. Our aim was to develop and validate a pain assessment tool based on objective behavioural cues tailored to outpatients undergoing colonoscopy: St. Paul's endoscopy comfort score (SPECS). METHODS: A single-centre, prospective study was conducted in consecutive adults undergoing planned outpatient colonoscopy. Patient comfort was independently assessed by the physician, nurse and a research assistant (observer) using the SPECS and the Gloucester scale (GS). In addition, the nurse-assessed patient comfort score (NAPCOMS), nonverbal pain Assessment tool (NPAT) and Richmond agitation sedation scale (RASS) were completed by the observer. Data on subject demographics, sedation dose and duration of the procedure were collected. Following the procedure, patients completed a patient satisfaction questionnaire, including a visual analogue scale (VAS) to measure their overall perceived pain during the procedure. RESULTS: The study enrolled 350 subjects. The SPECS showed excellent inter-rater reliability among all three raters with an intra-class coefficient (ICC) of 0.81 (95% CI, 0.78-0.84), while the GS showed good reliability with an ICC of 0.77 (95% CI, 0.73-0.80). The SPECS demonstrated moderate agreement with the patient-reported VAS ratings. CONCLUSIONS: The St. Paul's endoscopy comfort score was successfully validated, demonstrating excellent inter-rater reliability.

Benefit of Capsule Endoscopy in the Setting of Iron Deficiency Anemia in Patients Above Age 65.

BACKGROUND: Iron deficiency anemia (IDA) is a common indication for a capsule endoscopy (CE), which is often offered after a negative bidirectional endoscopy. Since malignancy is a concern in the older population with IDA, upper and lower endoscopic exams are typically performed. If these tests are negative, CE may be offered to evaluate the small intestine. However, choosing the ideal candidates who are most likely to benefit from a CE study is challenging. AIMS: The goal of this study was to assess the outcomes for CE in patients with IDA over age 65 and assess which factors are more likely to contribute to a positive CE yield. METHODS: A retrospective review of all CE studies at St. Paul's Hospital from January 2010 to June 2016 was conducted after ethics approval. Inclusion criteria included the following: age >65, hemoglobin <120 g/L, serum ferritin <70 µg/L, and at least one high-quality complete EGD/colonoscopy performed before CE. Variables to assess factors that are more likely to contribute to a positive capsule yield included use of anticoagulation medications, NSAIDs, PPIs, transfusion burden and cardiac disease. A Chi-Square test was then used to determine clinical predictive factors of a positive and negative study. RESULTS: There were 1149 CE studies that were reviewed, of which 130 CE studies met inclusion criteria. Fifty-one studies (40.6%) had positive findings, and from this group, 30 (58.8%) recommended active intervention (i.e., EGD, n = 8; colonoscopy, n = 12; push enteroscopy, n = 3; double-balloon [DB] enteroscopy, n = 2; small bowel resection, n = 3; escalation of Crohn's therapy, n = 2), while 21 (41.2%) were managed supportively, typically with iron supplementation. Most negative studies (73 of 79) recommended supportive therapy (other recommendations included hematological workup, n = 3; hiatal hernia repair, n = 1; proton-pump inhibitors [PPI] initiation, n = 1; stop donating blood, n = 1).A history of cardiac disease had a significant association with positive findings (0.54 versus 0.33, P = 0.001). Conversely, a known history of low ferritin levels (0.84 versus 0.68, P = 0.046) and a known history of hiatal hernia (0.25 versus 0.08, P = 0.012) were associated with a negative study. CONCLUSIONS: These findings suggest that the clinical yield of CE in IDA in patients above age 65 is relatively low. The majority of all CE studies recommended supportive therapy or repeat endoscopic exams (EGD/colonoscopy) of areas previously assessed and lesions missed. Provided that initial endoscopic exams were thorough and Crohn's disease management was optimized, the overall rate of changing management significantly was low at five of 130 studies (two DB enteroscopies and three resections) or 3.8%. Clinical factors focusing on cardiac history, ferritin levels and the presence of a hiatal hernia may be of utility to predict benefit of CE. Emphasis on these data may help select more appropriate patients for capsule endoscopy.

Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group.

Description: This update of the 2010 International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding (UGIB) refines previous important statements and presents new clinically relevant recommendations. Methods: An international multidisciplinary group of experts developed the recommendations. Data sources included evidence summarized in previous recommendations, as well as systematic reviews and trials identified from a series of literature searches of several electronic bibliographic databases from inception to April 2018. Using an iterative process, group members formulated key questions. Two methodologists prepared evidence profiles and assessed quality (certainty) of evidence relevant to the key questions according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Group members reviewed the evidence profiles and, using a consensus process, voted on recommendations and determined the strength of recommendations as strong or conditional. Recommendations: Preendoscopic management: The group suggests using a Glasgow Blatchford score of 1 or less to identify patients at very low risk for rebleeding, who may not require hospitalization. In patients without cardiovascular disease, the suggested hemoglobin threshold for blood transfusion is less than 80 g/L, with a higher threshold for those with cardiovascular disease. Endoscopic management: The group suggests that patients with acute UGIB undergo endoscopy within 24 hours of presentation. Thermocoagulation and sclerosant injection are recommended, and clips are suggested, for endoscopic therapy in patients with high-risk stigmata. Use of TC-325 (hemostatic powder) was suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers. Pharmacologic management: The group recommends that patients with bleeding ulcers with high-risk stigmata who have had successful endoscopic therapy receive high-dose proton-pump inhibitor (PPI) therapy (intravenous loading dose followed by continuous infusion) for 3 days. For these high-risk patients, continued oral PPI therapy is suggested twice daily through 14 days, then once daily for a total duration that depends on the nature of the bleeding lesion. Secondary prophylaxis: The group suggests PPI therapy for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis.

Capsule Endoscopy and Small Bowel Enteroscopy: Have They Rendered the Radiologist Obsolete?

Capsule endoscopy (CE) provides visualization of small bowel mucosa for evidence of inflammation. Given its ability to detect subtle mucosal changes, CE is recommended in the diagnostic work-up of small bowel Crohn disease (CD) and also in monitoring mucosal response to therapy in nonstricturing CD. Patency capsule and cross-sectional imaging can reduce risk of capsule retention in patients with suspected stenotic disease. CE is complementary to magnetic resonance enterography, which can provide extraintestinal information. Device-assisted enteroscopy has limited role in CD.

PANCREATIC SAFETY IN STUDIES OF THE GLUCAGON-LIKE PEPTIDE-1 RECEPTOR AGONIST ALBIGLUTIDE.

Objective: Albiglutide, a glucagon-like peptide-1 receptor agonist (GLP-1RA), reduces glycated hemoglobin with a low risk of hypoglycemia in patients with type 2 diabetes. The relationship between GLP-1RAs and risk of pancreatitis is unresolved. This independent, rigorous, expert review of the albiglutide HARMONY Phase III clinical program examined suspected cases of acute pancreatitis. Methods: An independent pancreatitis adjudication committee (PAC), composed of physicians with expertise in gastroenterology and pancreatic disease, was prospectively established to review cases of suspected acute pancreatitis in the HARMONY studies. Results: Patients treated in Phase III trials with albiglutide (n = 2,365), or active or placebo comparators (n = 2,530), averaged 56 years of age with a mean 8.3-year diabetes duration. Across the 8 studies, the PAC reviewed potential cases of treatment-emergent acute pancreatitis in 43 patients. Definite or probable acute pancreatitis was adjudicated for 11 patients (8 albiglutide; 3 active comparators). Most of these were considered by the PAC to be at least possibly related to study treatment (6 of 8 albiglutide cases and 2 of 3 active comparator cases). Both cases in the active comparator group adjudicated as definite or probable pancreatitis with at least a possible relationship to study treatment were in patients treated with a GLP-1RA. The frequency of pancreatitis was higher among patients treated with albiglutide (6/2,365, 0.3%) than with placebo (0/486, 0%) or active comparators (2/2,062, 0.08%). Conclusion: In the HARMONY Phase III program, adjudicated cases of acute pancreatitis were uncommon. However, within the limitations of available data, the incidence of acute pancreatitis with albiglutide appears to be within the range described for other studies of GLP-1RAs. Abbreviations: AE = adverse event; CI = confidence interval; DPP-4 = dipeptidyl peptidase-4; GLP-1 = glucagon-like peptide-1; GLP-1RA = glucagon-like peptide-1 receptor agonist; MH-OR = Mantel-Haenszel odds ratio; OR = odds ratio; PAC = pancreatitis adjudication committee; SAE = serious adverse event; ULN = upper limit of normal.

Characteristics of Patients with Colonic Polyps Requiring Segmental Resection.

Background: It is unclear if the availability of new techniques for removal of large colonic polyps has affected the use of segmental colon resection. We sought to evaluate the characteristics of polyps undergoing surgical resection, including involvement of therapeutic gastroenterologists (TG). Methods: 484 patients had a colonic resection; 165 (34%) were identified from the pathology database with polyp, adenoma, or mass in the clinical history field; these charts were reviewed. Results: 128 patients (mean age 68 yrs, 72% male) were included. The mean polyp size was 2.9 cm (0.4 cm-12.0 cm). Adenocarcinoma was diagnosed in 50 (39.1%). 97 (75.8%) patients had a polyp that was felt to be unresectable by EMR, and 31 (24.2%) underwent successful EMR followed by surgery for adenocarcinoma (n = 29). The indication for surgery in those with unresectable polyps was variable and was not clearly documented in 51 (52.6%); only 17 of these patients (17.5%) had a TG involved. Conclusion: A high proportion of polyps managed by segmental resection did not contain adenocarcinoma. This data suggests that even in a tertiary care center where advanced endoscopic techniques are easily available, they are not always utilized. Educational endeavors to ensure that ideal pathways of intervention are utilized require implementation.