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Gastric signet ring cell adenocarcinoma (SRCA) is an aggressive malignancy primarily diagnosed in advanced stages. Metastasis to other organ systems is uncommon, however, associated with poor prognosis. We present a young patient with persistent pain in the testicle. Histopathologic examination of the resected testicle revealed metastatic signet ring adenocarcinoma prompting follow-up endoscopy with biopsy confirming gastric SRCA. After 10 months of systemic chemotherapy, the patient developed worsening headaches, and cerebrospinal fluid cytology confirmed leptomeningeal metastasis. This case underscores the rare manifestation of SRCA and the importance of vigilance for atypical presentations to ensure timely diagnosis and management.
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We report the case of an 18-year-old male with a medical history of microvillous inclusion disease (MID) and notable surgical history of small bowel, liver, and pancreas transplant who presented with massive jejunal and cecal varices. Endoscopy findings demonstrated a large grape-like cluster, with subsequent CT angiography (CTA) showing other variceal lesions in the cecum. The patient was transferred to the original transplant center for recommended open surgical evaluation and combined interventional radiology (IR) embolization of varices. MID is a rare genetic disorder caused by mutations in the Myosin VB (MYO5B) gene leading to a lack of myosin Vb. Patients subsequently develop liver damage at birth, which necessitates a small bowel/liver transplant in childhood.
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The altered anatomy of patients after Roux-en-Y gastric bypass (RYGB) surgery creates technical challenges for endoscopic and surgical treatment of gallstones. We present a unique case of a post-RYGB patient with complicated gallbladder surgery requiring coiling and embolization of the cystic duct for bile leak. The cystic duct coils migrated out into the bile duct forming a nidus for infection and biliary obstruction, which was resolved using the novel endoscopic ultrasound-directed transgastric routine endoscopic retrograde cholangiopancreatography technique, with successful transpapillary removal of cystic duct coils in RYGB anatomy.
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BACKGROUND AND AIMS: Gastroenterology fellowships need to ensure that trainees achieve competence in upper endoscopy (EGD) and colonoscopy. Because the impact of structured feedback remains unknown in endoscopy training, this study compared the effect of structured feedback with standard feedback on trainee learning curves for EGD and colonoscopy. METHODS: In this multicenter, cluster, randomized controlled trial, trainees received either individualized quarterly learning curves or feedback standard to their fellowship. Assessment was performed in all trainees using the Assessment of Competency in Endoscopy tool on 5 consecutive procedures after every 25 EGDs and colonoscopies. Individual learning curves were created using cumulative sum (CUSUM) analysis. The primary outcome was the mean CUSUM score in overall technical and overall cognitive skills. RESULTS: In all, 13 programs including 132 trainees participated. The intervention arm (6 programs, 51 trainees) contributed 558 EGD and 600 colonoscopy assessments. The control arm (7 programs, 81 trainees) provided 305 EGD and 468 colonoscopy assessments. For EGD, the intervention arm (-.7 [standard deviation {SD}, 1.3]) had a superior mean CUSUM score in overall cognitive skills compared with the control arm (1.6 [SD, .8], P = .03) but not in overall technical skills (intervention, -.26 [SD, 1.4]; control, 1.76 [SD, .7]; P = .06). For colonoscopy, no differences were found between the 2 arms in overall cognitive skills (intervention, -.7 [SD, 1.3]; control, .7 [SD, 1.3]; P = .95) or overall technical skills (intervention, .1 [SD, 1.5]; control, -.1 [SD, 1.5]; P = .77). CONCLUSIONS: Quarterly feedback in the form of individualized learning curves did not affect learning curves for EGD and colonoscopy in a clinically meaningful manner. (Clinical trial registration number: NCT02891304.).
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Curva de Aprendizaje , Competencia Clínica , Colonoscopía , Retroalimentación , Gastroenterología/educación , HumanosRESUMEN
PURPOSE: The Next Accreditation System requires training programs to demonstrate competence among trainees. Within gastroenterology (GI), there are limited data describing learning curves and structured assessment of competence in esophagogastroduodenoscopy (EGD) and colonoscopy. In this study, the authors aimed to demonstrate the feasibility of a centralized feedback system to assess endoscopy learning curves among GI trainees in EGD and colonoscopy. METHOD: During academic year 2016-2017, the authors performed a prospective multicenter cohort study, inviting participants from multiple GI training programs. Trainee technical and cognitive skills were assessed using a validated competence assessment tool. An integrated, comprehensive data collection and reporting system was created to apply cumulative sum analysis to generate learning curves that were shared with program directors and trainees on a quarterly basis. RESULTS: Out of 183 fellowships invited, 129 trainees from 12 GI fellowships participated, with an overall trainee participation rate of 72.1% (93/129); the highest participation level was among first-year trainees (90.9%; 80/88), and the lowest was among third-year trainees (51.2%; 27/53). In all, 1,385 EGDs and 1,293 colonoscopies were assessed. On aggregate learning curve analysis, third-year trainees achieved competence in overall technical and cognitive skills, while first- and second-year trainees demonstrated the need for ongoing supervision and training in the majority of technical and cognitive skills. CONCLUSIONS: This study demonstrated the feasibility of using a centralized feedback system for the evaluation and documentation of trainee performance in EGD and colonoscopy. Furthermore, third-year trainees achieved competence in both endoscopic procedures, validating the effectiveness of current training programs.
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Colonoscopía/educación , Endoscopía del Sistema Digestivo/educación , Gastroenterología/educación , Acreditación , Competencia Clínica , Estudios de Factibilidad , Femenino , Humanos , Curva de Aprendizaje , Masculino , Evaluación de Programas y Proyectos de Salud , Estudios ProspectivosRESUMEN
Complete esophageal strictures are rare complications in patients who have received head and neck radiation therapy. Although mild strictures are generally amenable to dilation or stenting, management of these debilitating strictures is not well established. Treatment of long-segment obstructions is particularly complicated because documented techniques generally apply for strictures up to 3 cm in length. This report describes a successful recanalization of a long-segment complete esophageal stricture using combined antegrade-retrograde endoscopic therapy with adjunctive fluoroscopic techniques.
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BACKGROUND & AIMS: Fiducial markers are inert radiopaque gold or carbon markers implanted in or near pancreatic tumor to demarcate areas for image-guided radiation therapy. Endoscopic ultrasound (EUS) pre-loaded fiducial needles (PLNs) have been developed to circumvent technical issues associated with traditional back-loaded fiducials (BLNs). We performed a randomized controlled trial to compare procedure times in patients with pancreatic adenocarcinoma undergoing EUS-guided placement of BLNs vs PLNs. METHODS: In a prospective study, 44 patients with pancreatic adenocarcinoma referred for fiducial marker placement at 2 tertiary care centers were assigned to groups that received PLNs (n = 22) or BLNs (n = 22); each group had the same proportion of patients with tumors of different locations (head or neck vs body or tail).The procedure was standardized among all endoscopists and placement of a minimum of 3 markers inside the tumor was defined as technical success. The times for procedure and fiducial placement were recorded, total number of fiducial markers used documented, and grade of procedure difficulty ranked by passing the needle or deploying the fiducials. Other recorded variables included tumor characteristics, fluoroscopy use, and the number of fiducials clearly seen by EUS and fluoroscopy. The primary aim was to compare the duration of EUS-guided fiducial insertion of BLNs vs PLNs. RESULTS: The median placement time was significantly shorter in the PLN group (9 min) than the BLN group (16 min) (P < .001). However, the 44% reduction in time did not reach pre-specified levels (≥60%). Similar results were found after stratifying by tumor location. Deployment of BLNs was easier than deployment of PLNs (P = .03). There was no significant difference between groups in technical success, number of fiducials placed, EUS or fluoroscopic visualization, or adverse events. During simulation computed tomography and image-guided radiation therapy, there was no difference between groups in visualization of fiducials, migration rate, or accuracy of placement. CONCLUSIONS: In a randomized controlled trial of 44 patients with pancreatic adenocarcinoma, we found EUS-guided placement of PLNs to require less time and produce similar results compared with BLNs. Further refinements in PLN delivery system are needed to increase the ease of deployment. Clinicaltrials.gov no: NCT02332863.
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Adenocarcinoma/radioterapia , Endosonografía/instrumentación , Marcadores Fiduciales , Agujas , Neoplasias Pancreáticas/radioterapia , Implantación de Prótesis/instrumentación , Radioterapia Guiada por Imagen , Anciano , Femenino , Fluoroscopía , Humanos , Masculino , Persona de Mediana Edad , Factores de TiempoRESUMEN
BACKGROUND: Biliary-enteric anastomotic strictures (AS) in long-limb surgical biliary bypass (LLBB) require percutaneous transhepatic biliary drains (PTBD), enteroscopy-assisted ERCP (E-ERCP), or surgical revision. AIM: To compare E-ERCP and PTBD for AS treatment. METHODS: E-ERCP stricturoplasty included dilation, cautery, and stent; PTBD included balloon dilation and serial drain upsizing events. RESULTS: From May 2008 to October 2015, 71 patients (37 M, median age 52) had E-ERCP (n = 45) or PTBD (n = 26) for AS in Roux-en-Y hepaticojejunostomy: liver transplant (n = 28), cholecystectomy injury revision (n = 21), other (n = 13) or Whipple's resection (n = 9). Median follow-up is 11 months (range 1-56) in 67 (94%) patients. Technical success, clinical improvement, and adverse events between E-ERCP and PTBD were similar (76% vs. 77%, p = 0.89; 82% vs. 85%, p = 0.80, and 6% vs. 5%, p = 0.60, respectively). However, E-ERCP had fewer post-procedural hospitalization days (0.2 ± 0.65 vs. 4.5±10, p = 0.0001), mean procedures (4.4 ± 6.3 vs. 9.5 ± 8, p = 0.006), and median months of treatment to resolve AS (1, range 1-22 vs. 7, range 3-23; p = 0.003). Two patients in PTBD group required surgery. CONCLUSIONS: (1) Technical success and clinical improvement are seen in the majority of LLBB patients with biliary-enteric AS undergoing E-ERCP or PTBD. (2) E-ERCP is associated with fewer procedures, post-procedure hospitalization days, and months to resolve AS. When expertise is available, E-ERCP to identify and treat AS should be considered as an alternative to PTBD.
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Conductos Biliares/cirugía , Colangiopancreatografia Retrógrada Endoscópica/métodos , Drenaje/métodos , Endoscopía Gastrointestinal , Intestino Delgado/cirugía , Anastomosis Quirúrgica/efectos adversos , Colangiopancreatografia Retrógrada Endoscópica/efectos adversos , Constricción Patológica/etiología , Constricción Patológica/cirugía , Drenaje/efectos adversos , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND AND AIMS: Surveillance endoscopy is recommended after endoscopic eradication therapy (EET) for Barrett's esophagus (BE) because of the risk of recurrence. Currently recommended biopsy protocols are based on expert opinion and consist of sampling visible lesions followed by random 4-quadrant biopsy sampling throughout the length of the original BE segment. Despite this protocol, some recurrences are not visibly identified. We aimed to identify the anatomic location and histology of recurrences after successful EET with the goal of developing a more efficient and evidence-based surveillance biopsy protocol. METHODS: We performed an analysis of a large multicenter database of 443 patients who underwent EET and achieved complete eradication of intestinal metaplasia (CE-IM) from 2005 to 2015. The endoscopic location of recurrence relative to the squamocolumnar junction (SCJ), visible recurrence identified during surveillance endoscopy, and time to recurrence after CE-IM were assessed. RESULTS: Fifty patients with BE recurrence were studied in the final analysis. Seventeen patients (34%) had nonvisible recurrences. In this group, biopsy specimens demonstrating recurrence were taken from within 2 cm of the SCJ in 16 of these 17 patients (94%). Overall, 49 of 50 recurrences (98%) occurred either within 2 cm of the SCJ or at the site of a visible lesion. Late recurrences (>1 year) were more likely to be visible than early (<1 year) recurrences (P = .006). CONCLUSIONS: Recurrence after EET detected by random biopsy sampling is identified predominately in the distal esophagus and occurs earlier than visible recurrences. As such, we suggest a modified biopsy protocol with targeted sampling of visible lesions followed by random biopsy sampling within 2 cm of the SCJ to optimize detection of recurrence after EET. (Clinical trial registration number: NCT02634645.).
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Adenocarcinoma/patología , Esófago de Barrett/patología , Biopsia/métodos , Neoplasias Esofágicas/patología , Esófago/patología , Recurrencia Local de Neoplasia/patología , Adenocarcinoma/diagnóstico , Adenocarcinoma/cirugía , Anciano , Esófago de Barrett/diagnóstico , Esófago de Barrett/cirugía , Resección Endoscópica de la Mucosa , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/cirugía , Esofagoscopía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/diagnóstico , Ablación por Radiofrecuencia , Recurrencia , Espera VigilanteRESUMEN
BACKGROUND AND AIMS: Through-the-needle microforceps are a recent addition to the EUS armamentarium for evaluation of pancreatic cystic lesions (PCLs). The main aim of this study was to assess the technical feasibility, diagnostic yield, and safety of EUS-guided microforceps biopsy for PCLs. METHODS: Our electronic endoscopy database was queried to identify patients who underwent EUS-guided FNA (EUS-FNA) of PCLs and microforceps biopsies during the same procedure. A biopsy was done on the wall of the cyst with the microforceps through the 19-gauge needle, and cyst fluid was collected for cytology and carcinoembryonic antigen (CEA) levels. Adverse events were recorded per published American Society for Gastrointestinal Endoscopy criteria. RESULTS: Twenty-seven patients underwent EUS-FNA and microforceps biopsy of PCLs from February 2016 to July 2017. Fourteen cysts were located in the pancreatic head and/or uncinate, and 13 were located in the body and/or tail region. Microforceps biopsies were technically successful in all cases and provided a pathology diagnosis in 24 of 27 cases (yield 88.9%). Microforceps biopsies diagnosed mucinous cyst in 9 patients (33.3%), serous cystadenoma in 4 (14.8%), neuroendocrine tumor in 1 (3.7%), and benign and/or inflammatory cyst in 10 (37.1%). In 7 patients (26%), microforceps biopsy results drastically changed the diagnosis, providing diagnoses otherwise not suggested by cytology or cyst fluid CEA levels. However, cytology provided a diagnosis of mucinous cyst in 4 cases (14.8%) not detected by microforceps biopsies. No adverse events were noted. CONCLUSION: Microforceps biopsies were associated with high technical success, and an excellent safety profile and may be a useful adjunctive tool, complementing existing EUS-FNA sampling protocols for PCLs.
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Biopsia/métodos , Cistadenoma Seroso/patología , Tumores Neuroendocrinos/patología , Quiste Pancreático/patología , Neoplasias Pancreáticas/patología , Adulto , Anciano , Anciano de 80 o más Años , Antígeno Carcinoembrionario/análisis , Líquido Quístico/química , Líquido Quístico/citología , Cistadenoma Seroso/diagnóstico , Biopsia por Aspiración con Aguja Fina Guiada por Ultrasonido Endoscópico/métodos , Endosonografía , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Tumores Neuroendocrinos/diagnóstico , Quiste Pancreático/diagnóstico , Neoplasias Pancreáticas/diagnóstico , Instrumentos QuirúrgicosRESUMEN
Cancer is fundamentally a genetic disease caused by mutational or epigenetic alterations in DNA. There has been a remarkable expansion of the molecular understanding of colonic carcinogenesis in the last 30 years and that understanding is changing many aspects of colorectal cancer care. It is becoming increasingly clear that there are genetic subsets of colorectal cancer that have different risk factors, prognosis, and response to treatment. This article provides a general update on colorectal cancer and highlights the ways that genetics is changing clinical care.
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Inestabilidad Cromosómica/genética , Neoplasias Colorrectales/genética , Islas de CpG , Metilación de ADN/genética , Proteína de la Poliposis Adenomatosa del Colon/genética , Cuidados Posteriores , Colonoscopía , Neoplasias Colorrectales/diagnóstico , Neoplasias Colorrectales/terapia , Neoplasias Colorrectales Hereditarias sin Poliposis/diagnóstico , Neoplasias Colorrectales Hereditarias sin Poliposis/genética , Neoplasias Colorrectales Hereditarias sin Poliposis/terapia , Detección Precoz del Cáncer , Humanos , Inestabilidad de Microsatélites , Mutación , Proteínas Proto-Oncogénicas B-raf/genética , Proteínas Proto-Oncogénicas p21(ras)/genéticaRESUMEN
BACKGROUND AND AIMS: Endoscopic ultrasound with fine needle aspiration (EUS-FNA) has become the standard of care in the evaluation of solid pancreatic lesions. Limited data exist on interobserver agreement (IOA) among cytopathologists in assessing solid pancreatic EUS-FNA specimens. This study aimed to evaluate IOA among cytopathologists in assessing EUS-FNA cytology specimens of solid pancreatic lesions using a novel standardized scoring system and to assess individual clinical and cytologic predictors of IOA. METHODS: Consecutive patients who underwent EUS-FNA of solid pancreatic lesions at a tertiary care referral center were included. EUS-FNA slides were evaluated by four blinded cytopathologists using a standardized scoring system that assessed final cytologic diagnosis and quantitative (number of nucleated/diagnostic cells) and qualitative (bloodiness, inflammation/necrosis, contamination, artifact) cytologic parameters. Final clinical diagnosis was based on final cytology, surgical pathology, or 1-year clinical follow-up.âIOA was calculated using multi-rater kappa (κ) statistics. Bivariate analyses were performed comparing cases with and without uniform agreement among the cytopathologists followed by logistic regression with backward elimination to model likelihood of uniform agreement. RESULTS: Ninety-nine patients were included (49â% males, mean age 64 years, mean lesion size 26âmm). IOA for final diagnosis was moderate (κâ=â0.45, 95â% confidence interval (CI) 0.4â-â0.49) with minimal improvement when combining suspicious and malignant diagnoses (κâ=â0.54, 95â%CI 0.49â-â0.6). The weighted kappa value for overall diagnosis was 0.65 (95â%CI 0.54â-â0.76). IOA was slight to fair (κâ=â0.04â-â0.32) for individual cytologic parameters. A final clinical diagnosis of malignancy was the most significant predictor of agreement [OR 3.99 (CI 1.52â-â10.49)]. CONCLUSIONS: Interobserver agreement among cytopathologists for pancreatic EUS-FNA specimens is moderate-substantial for the final cytologic diagnosis. The final clinical diagnosis of malignancy was the strongest predictor of agreement. These results have significant implications for patient management and need to be validated in future trials.
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GOAL: The primary aim of this study was to determine predictors of clinically significant computed tomography (CT) scans, paying particular attention to findings of previous CT scans. BACKGROUND: Use of CT to assess patients with Crohn's disease (CD) in the Emergency Department (ED) is both costly and exposes patients to high levels of ionizing radiation while not clearly improving outcomes. STUDY: Patients with CD who underwent CT scan in the Emergency Department from 2008 to 2011 at a tertiary referral center were assessed for clinically significant findings. A multivariable generalized estimating equation model with logit link and exchangeable working correlation structure was constructed to assess for independent predictors of CT scans with clinically significant findings. RESULTS: A total of 118 patients with CD underwent 194 CT scans. Ninety-two of 194 (47%) CT scans demonstrated clinically significant findings. Predictors of clinically significant CT scans included ileal disease involvement [odds ratios (OR) 3.47, P=0.01] and white blood cell count >12 (OR 2.1, P=0.03). Most notably, patients with a CT scan without clinically significant findings performed in the preceding month were significantly less likely to have a clinically significant CT scan (OR 0.23, P=0.005). CONCLUSIONS: Patients with CD who had a CT scan without significant findings the month prior are unlikely to have clinically significant CT findings. Ileal disease and an elevated white blood cell are predictive of clinically significant CT scans.
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Enfermedad de Crohn/diagnóstico por imagen , Servicio de Urgencia en Hospital/estadística & datos numéricos , Tomografía Computarizada por Rayos X/estadística & datos numéricos , Adulto , Boston , Grupos Diagnósticos Relacionados/estadística & datos numéricos , Femenino , Humanos , Masculino , Registros Médicos , Persona de Mediana Edad , Valor Predictivo de las PruebasRESUMEN
Pancreatic metastases are uncommon. They have been reported in lung cancer, gastrointestinal malignancies, breast cancer, renal cell carcinoma, melanoma, lymphoma and sarcoma, and usually have solid morphology. Cystic metastasis to the pancreas is even more rare with few case reports in the literature. However, with the increasing use of computed tomography and magnetic resonance imaging as well as endoscopic ultrasound, more such lesions may be detected. Metastasis to the pancreas from osteosarcoma is highly unusual, but can be seen with the increasing survival of patients with osteosarcoma. We present an extremely rare case of a predominantly cystic lesion of the pancreas, which was diagnosed as metastasis from osteosarcoma. The pathophysiology of the cystic component of the metastasis of osteosarcoma is unknown. Cystic necrotic degeneration of the solid metastasis or pancreatitis secondary to the metastasis with development of associated fluid collection can be considered. Metastasis should remain a differential consideration even for primarily cystic lesions of the pancreas.
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Neoplasias Óseas/patología , Osteosarcoma/secundario , Quiste Pancreático/patología , Neoplasias Pancreáticas/secundario , Neoplasias Óseas/terapia , Endosonografía , Femenino , Humanos , Persona de Mediana Edad , Osteosarcoma/terapia , Quiste Pancreático/terapia , Neoplasias Pancreáticas/terapia , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Computed tomography (CT) is used in the emergency department (ED) for triage of patients with gastrointestinal complaints. Patients with inflammatory bowel disease undergo radiologic studies for gastrointestinal symptoms and are at risk for excessive ionizing radiation exposure; however, the utility of CT in the ED in patients with ulcerative colitis (UC) is not clear. In this study, we assess the frequency and risk factors for clinically significant CT findings in patients with UC in the ED. METHODS: We retrospectively reviewed 163 consecutive cases of patients with UC who presented to a tertiary care ED and underwent abdominopelvic CT between June 2008 and December 2011. Using logistic regression, we identified predictors of significant CT findings and derived a model to predict CT scans without clinically significant findings. RESULTS: Of note, 63.2% (103/163) of CT scans had no clinically significant findings. Less than 2% of scans revealed complications related to UC. Predictors of CT scans without clinically significant findings included rectal bleeding or diarrhea (P < 0.001), use of 5-aminosalicylate (P = 0.011), or immunomodulator (P = 0.032). Alternatively, predictors of clinically significant CT findings included nausea and vomiting (P < 0.001), history of colectomy (P < 0.001), history of abdominal or pelvic surgery (P < 0.001), surgery within 1 month (P < 0.001), age (P = 0.004), elevated white blood cell count (P = 0.003), and no UC medications (P = 0.001). CONCLUSIONS: Most patients with UC who presented to the ED and underwent CT had no clinically significant findings. We devised a model to predict lack of clinically significant CT findings, which may assist in reducing cost and radiation exposure in patients with UC.
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Colitis Ulcerosa/diagnóstico por imagen , Servicio de Urgencia en Hospital/estadística & datos numéricos , Tomografía Computarizada por Rayos X/estadística & datos numéricos , Triaje/métodos , Adulto , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Factores de Riesgo , Tomografía Computarizada por Rayos X/efectos adversos , Procedimientos Innecesarios/estadística & datos numéricosRESUMEN
OPINION STATEMENT: The sessile serrated polyp (SSP), also known as sessile serrated adenoma, is the evil twin among the colorectal cancer precursors. As will be described, these lesions have multiple aliases (serrated adenoma, serrated polyp, or serrated lesion among others), they hang out in a bad neighborhood (the poorly prepped right colon), they hide behind a mask of mucus, they are difficult for witnesses (pathologists) to identify, they are difficult for police (endoscopists) to find, they are difficult to permanently remove from the society (high incomplete resection rate), they can be impulsive (progress rapidly to colorectal cancer (CRC)), and enforcers (gastroenterologists) do not know how best to control them (uncertain surveillance recommendations). There is no wonder that there is a need to understand these lesions well, learn how best to prevent the colonic mucosa from going down this errant path or, if that fails, detect these deviants and eradicate them from the colonic society. These lesions should be on endoscopists' most wanted list.
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PURPOSE: To evaluate the value of ICD-9-CM code for identifying celiac disease (CD). METHODS: We searched administrative data to identify all adults with ICD-9-CM diagnosis code 579.0 (CD) at three teaching hospitals between 2000 and 2010. We then stratified patients according to the presence/absence of relevant serology and endoscopy codes into four groups: None, serology, endoscopy, and both. A diagnostic algorithm was applied to define CD status. RESULTS: Through random sampling and appropriate weighting, the 1200 reviewed patients represented a cohort of 8,122 cases. The overall positive predictive value (PPV) of the ICD-9-CM code was 15% (95% confidence interval [CI], 13%-17%). Case identification by a diagnosis code alone had a PPV of 4%, whereas the group with diagnosis code plus both serology and endoscopy testing had a PPV of 49%. Independent predictors of CD were non-Hispanic white, ICD-9-CM-coded patient group, total number of a diagnosis code, and receiving a diagnosis code by a gastroenterologist. The model had an area under the curve of 0.87 (95% CI, 0.84-0.89). CONCLUSIONS: The performance of ICD-9-CM 579.0 alone for identifying CD is extremely poor. Adding other readily available administrative data significantly improves CD case identification. The proposed case finding strategy via administrative databases may facilitate future research on CD.
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Algoritmos , Enfermedad Celíaca/diagnóstico , Enfermedad Celíaca/epidemiología , Bases de Datos Factuales/estadística & datos numéricos , Clasificación Internacional de Enfermedades , Adulto , Anciano , Anciano de 80 o más Años , Enfermedad Celíaca/clasificación , Estudios de Cohortes , Femenino , Humanos , Masculino , Massachusetts/epidemiología , Persona de Mediana Edad , Valor Predictivo de las Pruebas , PrevalenciaRESUMEN
OBJECTIVE: To investigate whether season of birth is associated with celiac disease (CD). STUDY DESIGN: We performed a medical record review of 1964 patients with biopsy-proven CD at 3 teaching hospitals (2 pediatric centers and 1 adult center) between 2000 and 2010. The first positive small intestinal biopsy result defined age of diagnosis. The observed proportions of births in each season (spring [March-May], summer [June-August], fall [September-November], and winter [December-February]) were compared with the expected proportions using binomial probability tests. RESULTS: The mean age at diagnosis was 9.8 ± 5.0 years in the 2 pediatric centers and 43.6 ± 15.8 years in the adult center. The cohort was predominately female (69%). Overall, more patients were born in spring (27%) than in any other season: summer (25%), fall (25%), and winter (23%). In patients diagnosed before age 15 years, the spring birth excess was present in boys (33%; P = .0005), but not in girls (26%; P = .43). The sex difference in season of birth was less striking in patients with CD diagnosed at age ≥15 years. CONCLUSION: Season of birth is an environmental risk factor for CD, particularly in boys diagnosed before age 15 years. The results are consistent with a new theoretical model that integrates potential environmental factors (eg, gluten introduction, ultraviolet-B exposure, vitamin D status) and acute viral gastrointestinal infections in early childhood.