Frailty predicts mortality in patients with upper gastrointestinal bleed: a prospective cohort study.

BACKGROUND AND AIM: Evidence on the impact of frailty in patients with upper gastrointestinal bleed (UGIB) is limited. This study aims to define the role of frailty as defined by Canadian Study of Health and Aging clinical frailty scale (CSHA-CFS) in predicting mortality in UGIB. METHODS: A prospective single-center cohort study was conducted over 21 months on all consecutive patients with UGIB. Data on demographics, lab parameters, Glasgow Blatchford score, CSHA-CFS, Charlson Comorbidity Index, and AIMS65 score was recorded. The primary outcome was all-cause inpatient mortality. The secondary outcomes were all-cause 30-day mortality, 30-day rebleeding, 30-day readmission, hospital length of stay (LoS), intensive care unit (ICU) admission, need for repeat endoscopy, and need for blood transfusion. The data were evaluated using univariate and multivariate analysis. RESULTS: There were 298 eligible patients, of which 63% were males, median age was 68 years, 44% were from non-English-speaking background, and 72% had major comorbidities. The all-cause inpatient and 30-day mortality were 9.4% and 10.7%, respectively. In the multivariate analysis, CHSA-CFS was the independent predictor of all-cause inpatient mortality (OR 1.66; 95% CI 1.13-2.143; P = 0.010) and all-cause 30-day mortality (OR 1.83; 95% CI 1.26-2.67; P = 0.002). CHSA-CFS was not a significant predictor of 30-day rebleed, 30-day readmission, ICU admission, hospital LoS, or need for blood transfusion. CONCLUSION: Frailty is an important independent predictor of mortality in patients with UGIB. Frailty assessment can guide clinical decision making and allow targeting of health-care resource (Australia/New Zealand Clinical Trial Registry number: ACTRN12622000821796).

To scope or not - the challenges of managing patients with positive fecal occult blood test after recent colonoscopy.

BACKGROUND: Colorectal cancer (CRC) is a major health problem. There is minimal consensus of the appropriate approach to manage patients with positive immunochemical fecal occult blood test (iFOBT), following a recent colonoscopy. AIM: To determine the prevalence of advanced neoplasia in patients with a positive iFOBT after a recent colonoscopy, and clinical and endoscopic predictors for advanced neoplasia. METHODS: The study recruited iFOBT positive patients who underwent colonoscopy between July 2015 to March 2020. Data collected included demographics, clinical characteristics, previous and current colonoscopy findings. Primary outcome was the prevalence of CRC and advanced neoplasia in a patient with positive iFOBT and previous colonoscopy. Secondary outcomes included identifying any clinical and endoscopic predictors for advanced neoplasia. RESULTS: The study included 1051 patients (male 53.6%; median age 63). Forty-two (4.0%) patients were diagnosed with CRC, 513 (48.8%) with adenoma/sessile serrated lesion (A-SSL) and 257 (24.5%) with advanced A-SSL (AA-SSL). A previous colonoscopy had been performed in 319 (30.3%). In this cohort, four (1.3%) were diagnosed with CRC, 146 (45.8%) with A-SSL and 56 (17.6%) with AA-SSL. Among those who had a colonoscopy within 4 years, none had CRC and 7 had AA-SSL. Of the 732 patients with no prior colonoscopy, there were 38 CRCs (5.2%). Independent predictors for advanced neoplasia were male [odds ratio (OR) = 1.80; 95% confidence interval (CI): 1.35-2.40; P < 0.001), age (OR = 1.04; 95%CI: 1.02-1.06; P < 0.001) and no previous colonoscopy (OR = 2.07; 95%CI: 1.49-2.87; P < 0.001). CONCLUSION: A previous colonoscopy, irrespective of its result, was associated with low prevalence of advanced neoplasia, and if performed within four years of a positive iFOBT result, was protective against CRC.

Endoscopic ultrasound-guided gallbladder and bile duct drainage with lumen apposing metal stent: A large multicenter cohort (with videos).

BACKGROUND AND AIM: Cholecystectomy and endoscopic retrograde cholangiopancreatography are the gold standard for managing acute cholecystitis and malignant biliary obstruction, respectively. Recent advances in therapeutic endoscopic ultrasound (EUS) have provided alternatives for managing patients in whom these approaches fail, namely, EUS-guided gallbladder drainage (EUS-GB) and EUS-guided bile duct drainage (EUS-BD). We aimed to assess the technical and clinical success of these techniques in the largest multicenter cohort published to date. METHODS: A retrospective, multicenter, observational study involving 17 centers across Australia and New Zealand was conducted. All patients who had EUS-GB or EUS-BD performed in a participating center using a lumen apposing metal stent between 2016 and 2020 were included. Primary outcome was technical success, defined as intra-procedural successful drainage. Secondary outcomes included clinical success and 30-day mortality. RESULTS: One hundred and fifteen patients underwent EUS-GB (n = 49) or EUS-BD (n = 66). EUS-GB was technically successful in 47 (95.9%) while EUS-BD was successful in 60 (90.9%). All failed cases were due to maldeployment of the distal flange outside of the targeted lumen. Clinical success of EUS-GB was achieved in 39 (79.6%). No patients required subsequent cholecystectomy. Clinical success of EUS-BD was achieved in 52 (78.8 %). Thirty-day mortality was 14.3% for EUS-GB and 12.1% for EUS-BD. CONCLUSIONS: EUS-guided gallbladder drainage and EUS-BD are promising alternatives for managing nonsurgical candidates with cholecystitis and malignant biliary obstruction following failed endoscopic retrograde pancreatography. Both techniques delivered high technical success with acceptable clinical success. Further research is needed to investigate the gap between technical and clinical success.

Drainage of pancreatic fluid collections using a lumen-apposing metal stent with an electrocautery-enhanced delivery system.

BACKGROUND AND AIM: Our aim was to evaluate the efficacy and safety of a lumen-apposing metal stent with an electrocautery-enhanced delivery system (EDS-LAMS) for endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) in regular clinical practice. METHODS: A retrospective and subsequent prospective analysis was undertaken of all patients who underwent EUS-guided drainage of their PFCs using the EDS-LAMS at 17 tertiary therapeutic endoscopy centers. RESULTS: Two hundred eight cases of EDS-LAMS deployment were attempted in 202 patients (mean age 52.9 years) at time of evaluation. Ninety-seven patients had pancreatic pseudocysts (PPs), 75 walled-off pancreatic necrosis (WOPN), 10 acute peripancreatic fluid collections (APFCs), 6 acute necrotic collections (ANCs), and 14 postoperative collections (POCs). Procedural technical success was achieved in 202/208 cases (97.1%). Maldeployment occurred in 7/208 cases (3.4%). Clinical success was achieved in 142/160 (88.8%) patients (PP 90%, WOPN 85.2%, APFC 100%, ANC 75%, POC 100%). Delayed adverse events included stent migration in 15/202 (7.4%), stent occlusion and infection in 16/202 (7.9%), major bleeding in 4/202 (2%), and buried EDS-LAMS in 2/202 (1%). PFC recurrence occurred in 13/142 (9.2%) patients; 9/202 (4.5%) required surgical or radiological intervention for PFC management after EDS-LAMS insertion. CONCLUSIONS: This large international multicenter study evaluating the EDS-LAMS for drainage of PFCs in routine clinical practice suggests that the EDS-LAMS are safe and effective for drainage of all types of PFCs; however, further endoscopic therapy is often required for WOPN. Major bleeding was a rare complication in our cohort.

Prospective single-blinded single-center randomized controlled trial of Prep Kit-C and Moviprep: Does underlying inflammatory bowel disease impact tolerability and efficacy?

BACKGROUND: Colonoscopy remains the gold standard for detection of colonic disease. An optimal evaluation depends on adequate bowel cleansing. Patients with inflammatory bowel disease (IBD), require frequent endoscopic assessment for both activity and dysplasia assessment. Two commonly used bowel preparations in Australia are Prep Kit-C (Pc) and Moviprep (Mp). Little is known about tolerability, efficacy and safety of split protocols of Mp and Pc in both IBD and non-IBD patients. AIM: To primary aim was to compare the tolerability, efficacy and safety of split protocols of Mp and Pc in patients having a colonoscopy. The secondary aim was to compare the efficacy, tolerability and safety of either preparation in patients with or without IBD. METHODS: Patients were randomized to Pc or Mp bowel preparation. Patients completed a questionnaire to assess tolerability. Efficacy was assessed using the Ottawa Bowel Preparation Score. Serum electrolytes and renal function were collected one week prior to colonoscopy and on the day of colonoscopy. RESULTS: Of 338 patients met the inclusion criteria. Of 168 patients randomized to Mp and 170 to Pc. The efficacy of bowel preparation (mean Ottawa Bowel Preparation Score) was similar between Mp (5.4 ± 2.4) and Pc (5.1 ± 2.1) (P = 0.3). Mean tolerability scores were similar in Mp (11.84 ± 5.4) and Pc (10.99 ± 5.2; P = 0.17). 125 patients had IBD (73 had Crohn's Disease and 52 had Ulcerative colitis). Sixty-four IBD patients were allocated to Mp and 61 to Pc. In non-IBD patients, 104 were allocated to Mp and 109 to Pc. The mean tolerability score in the IBD group was lower than the non-IBD group (mean tolerability scores: IBD: 10.3 ± 5.1 and non-IBD: 12.0 ± 5.3; P = 0.01). IBD patients described more abdominal pain with Mp when compared with Pc; (Mp: 5.7 ± 4.4 vs Pc: 3.6 ± 2.6, P = 0.046). Serum magnesium level increased with Pc compared with Mp in all patients (mean increase in mmol/L: Mp: 0.03 ± 0.117 and Pc: 0.11 ± 0.106; P < 0.0001). CONCLUSION: In this study, the efficacy, tolerability and safety of Mp and Pc were similar in all patients. However, patients with IBD reported lower tolerability with both preparations. Specifically, IBD patients had more abdominal pain with Mp. These results should be considered when recommending bowel preparation especially to IBD patients.

Gastric Cancer Screening in Common Variable Immunodeficiency.

Individuals with common variable immunodeficiency (CVID) have an increased risk of gastric cancer, and gastrointestinal lymphoma, yet screening for premalignant gastric lesions is rarely offered routinely to these patients. Proposed screening protocols are not widely accepted and are based on gastric cancer risk factors that are not applicable to all CVID patients. Fifty-two CVID patients were recruited for screening gastroscopy irrespective of symptoms or blood results and were compared to 40 controls presenting for gastroscopy for other clinical indications. Overall, 34% of CVID patients had intestinal metaplasia (IM), atrophic gastritis or moderate to severe non-atrophic gastritis, which can increase the risk of gastric cancer, compared to 7.5% of controls (p < 0.01). Focal nodular lymphoid hyperplasia, a precursor lesion for gastrointestinal lymphoma, was seen in eight CVID patients (16%), one of whom was diagnosed with gastrointestinal lymphoma on the same endoscopy. High-risk gastric pathology was associated with increased time since diagnosis of CVID, smoking, Helicobacter pylori, a low-serum pepsinogen I concentration, and diarrhea, but not pepsinogen I/II ratio, iron studies, vitamin B12 levels or upper gastrointestinal symptoms. There was a lower rate of detection of IM when fewer biopsies were taken, and IM and gastric atrophy were rarely predicted by the endoscopist macroscopically, highlighting the need for standardized biopsy protocols. The prevalence of premalignant gastric lesions in patients with CVID highlights the need for routine gastric screening. We propose a novel gastric screening protocol to detect early premalignant lesions and reduce the risk of gastric cancer and gastric lymphoma in these patients.

The impact of wire caliber on ERCP outcomes: a multicenter randomized controlled trial of 0.025-inch and 0.035-inch guidewires.

BACKGROUND AND AIMS: Wire-guided biliary cannulation has been demonstrated to improve cannulation rates and reduce post-ERCP pancreatitis (PEP), but the impact of wire caliber has not been studied. This study compares successful cannulation rates and ERCP adverse events by using a 0.025-inch and 0.035-inch guidewire. METHODS: A randomized, single blinded, prospective, multicenter trial at 9 high-volume tertiary-care referral centers in the Asia-Pacific region was performed. Patients with an intact papilla and conventional anatomy who did not have malignancy in the head of the pancreas or ampulla and were undergoing ERCP were recruited. ERCP was performed by using a standardized cannulation algorithm, and patients were randomized to either a 0.025-inch or 0.035-inch guidewire. The primary outcomes of the study were successful wire-guided cannulation and the incidence of PEP. Overall successful cannulation and ERCP adverse events also were studied. RESULTS: A total of 710 patients were enrolled in the study. The primary wire-guided biliary cannulation rate was similar in 0.025-inch and 0.035-inch wire groups (80.7% vs 80.3%; P = .90). The rate of PEP between the 0.025-inch and the 0.035-inch wire groups did not differ significantly (7.8% vs 9.3%; P = .51). No differences were noted in secondary outcomes. CONCLUSION: Similar rates of successful cannulation and PEP were demonstrated in the use of 0.025-inch and 0.035-inch guidewires. (Clinical trial registration number: NCT01408264.).

Deep mural injury and perforation after colonic endoscopic mucosal resection: a new classification and analysis of risk factors.

OBJECTIVES: Perforation is the most serious complication associated with endoscopic mucosal resection (EMR). We propose a new classification for the appearance and integrity of the muscularis propria (MP) after EMR including various extents of deep mural injury (DMI). Risk factors for these injuries were analysed. DESIGN: Endoscopic images and histological specimens of consecutive patients undergoing EMR of colonic laterally spreading lesions ≥20 mm at a large Australian tertiary referral endoscopy unit were retrospectively analysed using our new DMI classification system. DMI was graded according to MP injury (I/II intact MP without/with fibrosis, III target sign, IV/V obvious transmural perforation without/with contamination). Histological specimens were examined for included MP and patient outcomes were recorded. All type III-V DMI signs were clipped if possible, types I and II DMI were clipped at the endoscopists' discretion. RESULTS: EMR was performed in 911 lesions (mean size 37 mm) in 802 patients (male sex 51.4%, mean age 67 years). DMI signs were identified in 83 patients (10.3%). Type III-V DMI was identified in 24 patients (3.0%); clipping was successfully performed in all patients. A clinically significant perforation occurred in two patients (0.2%). Only one of the 59 type I/II cases experienced a delayed perforation. 85.5% of patients with DMI were discharged on the same day, all without sequelae. On multivariable analysis, type III-V DMI was associated with transverse colon location (OR 3.55, p=0.028), en bloc resection (OR 3.84, p=0.005) and high-grade dysplasia or submucosal invasive cancer (OR 2.97, p 0.014). CONCLUSIONS: In this retrospective analysis, use of the new classification and management with clips appeared to be a safe approach. Advanced DMI types (III-V) occurred in 3.0% of patients and were associated with identifiable risk factors. Further prospective clinical studies should use this new classification. TRIAL REGISTRATION NUMBER: NCT01368289; results.

Advanced mucosal neoplasia of the anorectal junction: endoscopic resection technique and outcomes (with videos).

BACKGROUND: EMR at the anorectal junction (ARJ) is technically challenging. Issues of safety and procedural efficacy dictate that surgery is still performed as the primary management for noninvasive lesions in most centers. Modifications to the standard EMR technique may help to address the unique features and achieve safe and curative resection of most lesions. OBJECTIVE: To describe an effective and safe, modified EMR technique to remove advanced mucosal neoplasia (AMN) of the ARJ. DESIGN: Prospective, observational cohort study. SETTING: Academic, tertiary care referral center. PATIENTS: Patients undergoing EMR for AMN at the ARJ over 4.5 years, from June 2008 to December 2012. INTERVENTIONS: Use of long-acting local anesthetic in the submucosal injectate, endoscopic resection over the dentate line and hemorrhoidal columns, prophylactic antibiotics for resection of lesions at high risk for bacteremia, and cap and gastroscope-assisted resection. MAIN OUTCOME MEASUREMENTS: Procedural success and safety. RESULTS: Twenty-six patients with lesions involving the ARJ were referred for EMR (males 53.8%, median age 63, median lesion size 40 mm). Two patients went directly to surgery because of an endoscopic diagnosis of adenocarcinoma. EMR was performed in 24 lesions with complete adenoma clearance achieved in 100%. Four patients were admitted to the hospital. Focal adenoma recurrence was seen in 4 of 18 patients (22%) at first surveillance colonoscopy and was managed by snare diathermy resection. No recurrences were found at the second follow-up colonoscopy. Procedural success, adenoma recurrence, and admission rates were similar between EMRs performed at the ARJ and proximal rectum on univariate analysis (all P > .05). LIMITATIONS: Single tertiary center, nonrandomized study. CONCLUSIONS: Simple modifications to the EMR technique allow safe and effective treatment of AMN at the ARJ on an outpatient basis and should be the first-line management when the risk of invasive disease is low.

Duodenal eosinophilia and early satiety in functional dyspepsia: confirmation of a positive association in an Australian cohort.

BACKGROUND AND AIM: Functional dyspepsia (FD), defined by unexplained pain or discomfort centered in the upper abdomen, is common. Diagnosis and treatment of FD based on the symptom-based Rome criteria remains challenging. Recently, eosinophilia in the duodenum has been implicated in the pathophysiology of FD in adults, specifically increased eosinophils in early satiety and postprandial distress, but the association remains controversial. The aim of this study was to characterize upper gastrointestinal (GI) tract pathology, specifically duodenal eosinophilia, in an Australian cohort of patients with FD. METHODS: Patients prospectively referred for an upper GI endoscopy (n = 55; mean age, 49.6 years; 61.8% female) were stratified to FD cases (n = 33) and controls (n = 22) using Rome II criteria. All subjects completed a validated bowel symptom questionnaire. The eosinophil count per square millimeter in the duodenal bulb (D1) and second part (D2) was assessed and Helicobacter pylori status determined by gastric histology. Associations with clinical symptoms were assessed. RESULTS: Cases and controls were demographically similar. Duodenal eosinophilia was significantly increased in subjects experiencing early satiety (P = 0.01) and postprandial fullness (P = 0.001). This association was seen in D2 but not D1. Abdominal pain was associated with eosinophilia in both D1 (P = 0.02) and D2 (P = 0.005). Smoking was also associated with higher eosinophil counts in D2 (P = 0.007) and symptoms of early satiety (P = 0.02). CONCLUSIONS: Duodenal eosinophilia occurs in a subset of FD. The potential role of duodenal eosinophils in FD has implications for diagnosis and therapeutic trials.

Carbon dioxide insufflation reduces number of postprocedure admissions after endoscopic resection of large colonic lesions: a prospective cohort study.

BACKGROUND: Endoscopic resection (ER) for large colonic lesions is a safe and effective outpatient treatment. Postprocedural pain creates concern for perforation and often results in postprocedure admission (PPA). Carbon dioxide (CO(2)) insufflation has been shown to reduce pain scores after routine colonoscopy, but an influence on more critical outcomes such as PPA has not been shown. OBJECTIVE: To assess the outcomes of patients undergoing ER for large colonic lesions, comparing those having air versus those having CO(2) insufflation. DESIGN: Prospective, observational, cohort study. SETTING: Academic, high-volume, tertiary-care referral center. PATIENTS: Consecutive patients referred for ER of sessile colorectal polyps ≥20 mm. INTERVENTION: ER with air or CO(2). MAIN OUTCOME MEASUREMENTS: Rates of PPA, technical outcomes, complication rates. RESULTS: ER was performed on 575 lesions ≥20 mm, 228 with CO(2) insufflation. Mean lesion size was 36.5 mm. Lesion and patient characteristics were similar in both groups. The use of CO(2) was associated with a 62% decrease in the PPA rate from 8.9% to 3.4% (P = .01). This was mainly because of an 82% decrease in PPA for pain from 5.7% to 1.0% (P = .006). There were no significant difference in the rates of complications. Multiple logistical regression was performed. The adjusted odds ratio (OR) of PPA (OR 0.39; 95% confidence interval [CI], 0.16-0.95; P = .04) and PPA for pain (OR 0.18; 95% CI, 0.04-0.78; P = .02) in the CO(2) group remained significant. LIMITATIONS: Single center, nonrandomized study. CONCLUSION: CO(2) insufflation significantly reduces PPA after ER of large colonic lesions, primarily because of reduced PPA for pain. CO(2) insufflation should be routinely used during ER of large colonic lesions.