Association of sporadic and familial Barrett's esophagus with breast cancer.

Barrett's esophagus (BE) is the only known precursor to esophageal adenocarcinoma (EAC). Based on striking aggregation of breast cancer and BE/EAC within families as well as shared risk factors and molecular mechanisms of carcinogenesis, we hypothesized that BE may be associated with breast cancer. Pedigree analysis of families identified prospectively at multiple academic centers as part of the Familial Barrett's Esophagus Consortium (FBEC) was reviewed and families with aggregation of BE/EAC and breast cancer are reported. Additionally, using a matched case-control study design, we compared newly diagnosed BE cases in Caucasian females with breast cancer (cases) to Caucasian females without breast cancer (controls) who had undergone upper endoscopy (EGD). Two familial pedigrees, meeting a stringent inclusion criterion, manifested familial aggregation of BE/EAC and breast cancer in an autosomal dominant inheritance pattern with incomplete penetrance. From January 2008 to October 2016, 2812 breast cancer patient charts were identified, of which 213 were Caucasian females who underwent EGD. Six of 213 (2.82%) patients with breast cancer had pathology-confirmed BE, compared to 1 of 241 (0.41%) controls (P-value < 0.05). Selected families with BE/EAC show segregation of breast cancer. A breast cancer diagnosis is marginally associated with BE. We postulate a common susceptibility between BE/EAC and breast cancer.

Long-term randomized controlled trial of a novel nanopowder hemostatic agent (TC-325) for control of severe arterial upper gastrointestinal bleeding in a porcine model.

BACKGROUND AND STUDY AIM: Endoscopic therapy of brisk upper gastrointestinal bleeding remains challenging. A proprietary nanopowder (TC-325) has been proven to be effective in high pressure bleeding from external wounds. The efficacy and safety of TC-325 were assessed in a survival gastrointestinal bleeding animal model. METHOD: 10 animals were randomized to treatment or sham. All animals received intravenous antibiotics, H2-blockers and heparin (activated clotting time 2 × normal). In a sterile laparotomy the gastroepiploic vessels were dissected, inserted through a 1-cm gastrotomy, and freely exposed in the gastric lumen, and the exposed vessel lacerated by needle knife. The treatment group received TC-325 by a modified delivery catheter while the sham group received no endoscopic treatment. Time to hemostasis, and mortality at 60 minutes, 24 hours, 48 hours, and 7 days were noted. Necropsy was performed in all animals. RESULTS: Spurting arterial bleeding was achieved in all animals. No control animal showed hemostasis within the first hour compared with 100 % (5 / 5) in the treatment arm (mean 13.8 minutes, P < 0.0079). Durable hemostasis was achieved with no evidence of rebleeding after 1 and 24 hours in 80 % (4 / 5) of the treated animals compared with none in the control group ( P < 0.0098). None of the control animals survived more than 6 hours. Necropsy at 1 week in treated animals revealed healed gastrotomy without foreign body granuloma or embolization to the lung or brain. CONCLUSION: TC-325 is safe and highly effective in achieving hemostasis in an anticoagulated severe arterial gastrointestinal bleeding animal model.

Surveillance for pancreatic cancer in high-risk individuals.

Background: Surveillance of individuals at high risk of pancreatic ductal adenocarcinoma (PDAC) and its precursors might lead to better outcomes. The aim of this study was to determine the prevalence and outcomes of PDAC and high-risk neoplastic precursor lesions among such patients participating in surveillance programmes. Methods: A multicentre study was conducted through the International CAncer of the Pancreas Screening (CAPS) Consortium Registry to identify high-risk individuals who had undergone pancreatic resection or progressed to advanced PDAC while under surveillance. High-risk neoplastic precursor lesions were defined as: pancreatic intraepithelial neoplasia (PanIN) 3, intraductal papillary mucinous neoplasia (IPMN) with high-grade dysplasia, and pancreatic neuroendocrine tumours at least 2 cm in diameter. Results: Of 76 high-risk individuals identified in 11 surveillance programmes, 71 had undergone surgery and five had been diagnosed with inoperable PDAC. Of the 71 patients who underwent resection, 32 (45 per cent) had PDAC or a high-risk precursor (19 PDAC, 4 main-duct IPMN, 4 branch-duct IPMN, 5 PanIN-3); the other 39 patients had lesions thought to be associated with a lower risk of neoplastic progression. Age at least 65 years, female sex, carriage of a gene mutation and location of a lesion in the head/uncinate region were associated with high-risk precursor lesions or PDAC. The survival of high-risk individuals with low-risk neoplastic lesions did not differ from that in those with high-risk precursor lesions. Survival was worse among patients with PDAC. There was no surgery-related mortality. Conclusion: A high proportion of high-risk individuals who had surgical resection for screening- or surveillance-detected pancreatic lesions had a high-risk neoplastic precursor lesion or PDAC at the time of surgery. Survival was better in high-risk individuals who had either low- or high-risk neoplastic precursor lesions compared with that in patients who developed PDAC.

Antecedentes: Se podrían obtener mejores resultados con el seguimiento de individuos de alto riesgo para adenocarcinoma ductal pancreático (pancreatic ductal adenocarcinoma, PDAC) y lesiones precursoras. El objetivo de este estudio fue determinar la prevalencia y los resultados del PDAC y de las lesiones precursoras de alto riesgo neoplásico en pacientes que participaron en programas de seguimiento. Métodos: Se llevó a cabo un estudio multicéntrico a través del registro internacional del consorcio CAPS (Common Automotive Platform Standard) para identificar a las personas de alto riesgo que se habían sometido a una resección pancreática o habían progresado a PDAC avanzado mientras estaban en seguimiento. Se definieron como lesiones neoplásicas precursoras de alto riesgo la neoplasia intraepitelial pancreática de tipo 3 (PanIN­3), la neoplasia papilar mucinosa intraductal (intraductal papillary mucinous neoplasia, IPMN) con displasia de alto grado y los tumores neuroendocrinos pancreáticos (pancreatic neuroendocrine tumours, PanNET) de ≥ 2 cm de diámetro. Resultados: De 76 individuos con lesiones de alto riesgo identificados en 11 programas de seguimiento, 71 fueron tratados quirúrgicamente y 5 fueron diagnosticados de un PDAC inoperable. De las 71 resecciones, 32 (45%) tenían PDAC o una lesión precursora de alto riesgo (19 PDAC, 4 IPMN de conducto principal, 4 IPMN de rama secundaria y 5 PanIN­3). Los otros 39 pacientes tenían lesiones que se consideraron asociadas con un menor riesgo de progresión neoplásica. La edad ≥ 65 años, el sexo femenino, el ser portador de una mutación genética y la localización de la lesión en la cabeza/proceso uncinado fueron factores asociados a las lesiones precursoras de alto riesgo o al PDAC. No hubo diferencias en la supervivencia de individuos de alto riesgo con lesiones neoplásicas de bajo riesgo frente a aquellos que presentaron lesiones precursoras de alto riesgo. La supervivencia fue peor en los pacientes con PDAC. No hubo mortalidad relacionada con la cirugía. Conclusión: Un elevado porcentaje de individuos de alto riesgo que se sometieron a resección quirúrgica tras la detección de lesiones pancreáticas en el seguimiento tenían una lesión precursora neoplásica de alto riesgo o un PDAC. La supervivencia fue mejor en individuos de alto riesgo que tenían lesiones precursoras neoplásicas de bajo o alto riesgo en comparación con aquellos pacientes que habían desarrollado un PDAC.

The utility of contrast-enhanced endoscopic ultrasound in monitoring ethanol-induced pancreatic tissue ablation: a pilot study in a porcine model.

BACKGROUND AND STUDY AIMS: Pancreatic ablation is gaining popularity for the treatment of focal pancreatic lesions. The aim of our study was to evaluate local effects of intrapancreatic alcohol injection and the utility of contrast-enhanced endoscopic ultrasound (EUS) for its monitoring in a porcine model. METHODS: We performed four survival experiments on 50-kg pigs. Under linear EUS guidance, 0.5 mL of 50% ethanol plus purified carbon particle solution (GI Spot) was injected into the pancreatic body to create a focal area of pancreatic necrosis. The animals survived for 24-48 hours (pigs # 1, # 2, and # 3) and 7 days (pig # 4). EUS was then repeated with and without perflutren lipid microspheres (Definity) administration through the peripheral vein. Standard and microsphere-enhanced images of the pancreas were compared. Afterwards the animals were euthanized for necropsy. RESULTS: Alcohol injection caused focal pancreatic necrosis, which was barely seen by standard EUS as a subtle hypoechoic lesion 1 cm in diameter. Color and power Doppler EUS of this region did not reveal any blood flow. After intravenous injection of microspheres, color Doppler EUS revealed marked contrast enhancement of normal pancreatic parenchyma with a clearly delineated avascular alcohol-treated area, which on postmortem examination corresponded to the discrete necrotic area marked with carbon particles. CONCLUSIONS: EUS-guided alcohol injection consistently causes focal areas of pancreatic necrosis. Contrast-enhanced EUS with microspheres improves visualization of altered pancreatic vascular perfusion and can be used to facilitate detection of small pancreatic lesions and its follow-up post-ablation.

Phase II evaluation of preoperative chemoradiation and postoperative adjuvant chemotherapy for squamous cell and adenocarcinoma of the esophagus.

PURPOSE: This phase II trial evaluated continuous-infusion cisplatin and fluorouracil (5-FU) with radiotherapy followed by esophagectomy. The objectives of this trial were to determine the complete pathologic response rate, survival rate, toxicity, pattern of failure, and feasibility of administering adjuvant chemotherapy in patients with resectable cancer of the esophagus treated with preoperative chemoradiation. PATIENTS AND METHODS: Patients were staged using computed tomography, endoscopic ultrasound, and laparoscopy. The preoperative treatment plan consisted of continuous intravenous infusion of cisplatin and 5-FU and a total dose of 44 Gy of radiation. Esophagogastrectomy was planned for approximately 4 weeks after the completion of chemoradiotherapy. Paclitaxel and cisplatin were administered as postoperative adjuvant therapy. RESULTS: Forty-two patients were enrolled onto the trial. Of the 39 patients who proceeded to surgery, 29 responded to preoperative treatment: 11 achieved pathologic complete response (CR) and 18 achieved a lower posttreatment stage. Five patients had no change in stage, whereas eight had progressive disease (four with distant metastases and four with increases in the T and N stages). At a median follow-up of 30.2 months, the median survival time has not been reached and the 2-year survival rate is 62%. The median survival of pathologic complete responders has not been reached, whereas the 2-year survival rate of this group is 91% compared with 51% in patients with complete tumor resection with residual tumor (P =.03). CONCLUSION: An excellent survival rate, comparable to that of our prior preoperative trial, was achieved with lower doses of preoperative cisplatin and 5-FU concurrent with radiotherapy.

The impact of practice guidelines in the management of Barrett esophagus: a national prospective cohort study of physicians.

BACKGROUND: Surveillance of patients with Barrett esophagus (BE) is recommended to detect dysplasia and early cancer. In 1998, practice guidelines for the surveillance of patients with BE were developed under the auspices of the American College of Gastroenterology (ACG). Our objective is to assess physicians' awareness of agreement with and adherence to these guidelines. METHODS: A national prospective cohort study of practicing gastroenterologists who completed a self-administered questionnaire containing case studies prior to the release of the guidelines and another survey 18 months later. Analysis of adherence to the guidelines was done using the McNemar chi(2) test. RESULTS: Of the 154 gastroenterologists (66%) who responded to the follow-up survey, more than half (55%) were aware of the guidelines, and members of the ACG were more likely to know of their existence than nonmembers (61% vs 38%; P =.01). Overall, about 27% of physicians reported practicing in accordance with the guidelines at baseline; adherence increased modestly to 38% in the 18-month follow-up (P =.04) and was inversely related to fee-for-service reimbursement. Awareness was not associated with an increased likelihood of adherence, but agreement with the guidelines was strongly correlated with adherence (P<.001). The most frequent reasons for disagreement were concerns about liability, cancer risk, and inadequate evidence. CONCLUSIONS: Awareness of the guidelines published by the ACG was low. Guideline awareness did not predict adherence. Improvement in guideline adherence will require steps beyond mere dissemination and promotion. Addressing disagreements about liability, disease risk, and scientific evidence as well as restructuring payment incentives may help achieve optimal practice.

Quantitative laser scanning confocal autofluorescence microscopy of normal, premalignant, and malignant colonic tissues.

Laser scanning confocal autofluorescence microscopy (LSCAM) using 351- to 364-nm excitation light was used to quantitatively compare fluorescent spectral emission of unstained, frozen histological sections of normal, premalignant, and malignant colonic tissues. To identify the spatial origins of fluorescent signals accurately, the same frozen section slides used for microscopy were fixed and histochemically stained immediately following LSCAM imaging. Tissue fluorescence emission was quantified in terms of the intrinsic fluorescence coefficient beta (lambda), defined as the fluorescence power per unit tissue volume per unit wavelength (centered at lambda) divided by the incident light irradiance. Over all emission wavelengths, colonic tissues emitted autofluorescence ranging from beta (lambda) approximately 10(-1.5) to 10(-3.0) cm-1. In the 530- to 610-nm spectral region, markedly increased autofluorescence (beta up to 10(-2.5)) was observed in the dysplastic cells of adenomatous polyps, as compared to normal epithelial cells. Compared to adenomatous polyps, decreased dysplastic cell autofluorescence was observed in adenocarcinoma. The brightest fluorescence in the lamina propria, which was attributed to eosinophils (beta approximately 10(-2.5)) in previous studies, was also observed in other granular structures (beta up to 10(-1.4)). LSCAM reveals quantitative significant differences in fluorescence emission between normal and diseased colonic tissues.

Next-generation sequencing of endoscopic biopsies identifies ARID1A as a tumor-suppressor gene in Barrett's esophagus.

The incidence of Barrett's esophagus (BE)-associated esophageal adenocarcinoma (EAC) is increasing. Next-generation sequencing (NGS) provides an unprecedented opportunity to uncover genomic alterations during BE pathogenesis and progression to EAC, but treatment-naive surgical specimens are scarce. The objective of this study was to establish the feasibility of using widely available endoscopic mucosal biopsies for successful NGS, using samples obtained from a BE 'progressor'. Paired-end whole-genome NGS was performed on the Illumina platform using libraries generated from mucosal biopsies of normal squamous epithelium (NSE), BE and EAC obtained from a patient who progressed to adenocarcinoma during endoscopic surveillance. Selective validation studies, including Sanger sequencing, immunohistochemistry and functional assays, were performed to confirm the NGS findings. NGS identified somatic nonsense mutations of AT-rich interactive domain 1A (SWI like) (ARID1A) and PPIE and an additional 37 missense mutations in BE and/or EAC, which were confirmed by Sanger sequencing. ARID1A mutations were detected in 15% (3/20) high-grade dysplasia (HGD)/EAC patients. Immunohistochemistry performed on an independent archival cohort demonstrated ARID1A protein loss in 0% (0/76), 4.9% (2/40), 14.3% (4/28), 16.0% (8/50) and 12.2% (12/98) of NSE, BE, low-grade dysplasia, HGD and EAC tissues, respectively, and was inversely associated with nuclear p53 accumulation (P=0.028). Enhanced cell growth, proliferation and invasion were observed on ARID1A knockdown in EAC cells. In addition, genes downstream of ARID1A that potentially contribute to the ARID1A knockdown phenotype were identified. Our studies establish the feasibility of using mucosal biopsies for NGS, which should enable the comparative analysis of larger 'progressor' versus 'non-progressor' cohorts. Further, we identify ARID1A as a novel tumor-suppressor gene in BE pathogenesis, reiterating the importance of aberrant chromatin in the metaplasia-dysplasia sequence.

The safety of intravenous fluorescein for confocal laser endomicroscopy in the gastrointestinal tract.

BACKGROUND: Confocal laser endomicroscopy (CLE) is rapidly emerging as a valuable tool for gastrointestinal endoscopic imaging. Fluorescent contrast agents are used to optimize imaging with CLE, and intravenous fluorescein is the most widely used contrast agent. Fluorescein is FDA-cleared for diagnostic angiography of the retina. For these indications, the safety profile of fluorescein has been well-documented; however, to date, fluorescein is not cleared for use with CLE. AIMS: To estimate the rate of serious and total adverse events attributable to intravenous fluorescein when used for gastrointestinal CLE. METHODS: We performed a cross sectional survey of 16 International Academic Medical Centres with active research protocols in CLE that involved intravenous fluorescein. Centres using i.v. fluorescein for CLE who were actively monitored for adverse events were included. RESULTS: Sixteen centres performed 2272 gastrointestinal CLE procedures. The most common dose of contrast agent was 2.5-5 mL of 10% sodium fluorescein. No serious adverse events were reported. Mild adverse events occurred in 1.4% of individuals, including nausea/vomiting, transient hypotension without shock, injection site erythema, diffuse rash and mild epigastric pain. The limitation is that only immediate post procedure events were actively monitored. CONCLUSIONS: Use of intravenous fluorescein for gastrointestinal CLE appears to be safe with few acute complications.

Is blood the ideal submucosal cushioning agent? A comparative study in a porcine model.

BACKGROUND AND STUDY AIMS: Creation of a submucosal cushion before endoscopic mucosal resection (EMR) significantly reduces perforation risk. We evaluated six solutions as cushioning agents in live pigs. MATERIAL AND METHODS: 5 ml of normal saline, normal saline plus epinephrine, albumin 12.5 %, albumin 25 %, hydroxypropyl methylcellulose, and the pig's own whole blood were endoscopically injected into the porcine esophageal submucosa. Blood was obtained from a peripheral vein immediately before injection. Injections were made every 4 cm from the gastroesophageal junction. The time from completion of the injection to disappearance of the cushion was recorded. Endoscopy was repeated at 48 hours post injection. Two EMRs were performed after blood injection. Statistical analysis employed one-way analysis of variance followed by pairwise T test comparisons using the Bonferroni correction. RESULTS: Five animal experiments were completed. The mean time to dissipation of the submucosal cushion was shortest for saline plus epinephrine sites (2.87 minutes, SD 2.21) followed by the saline (4.8 minutes, SD 1.56), albumin 12.5 % (5.68 minutes, SD 3.48), albumin 25 % (7.83 minutes, SD 2.02), hydroxypropyl methylcellulose (9.77 minutes, SD 1.55), and blood sites (38.6 minutes, SD 6.07). Injection of blood resulted in significantly longer mucosal elevation than any other solution ( P < 0.0007). Blood from the cushion did not hamper visualization and facilitated EMR. CONCLUSION: Blood produces the most durable cushion compared with standard agents, also having the advantages of being readily available and without cost. Albumin 25 % provides as durable a cushion as hydroxypropyl methylcellulose.

Endoscopic ultrasonography (EUS) and EUS-guided fine needle aspiration for accurate staging of rectal cancer: explanation of tumor staging and a case report.

This article describes the diagnosis, staging, and therapeutic options for rectal cancer and the importance of endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration (FNA) as a relatively new diagnostic modality. A case study is presented from initial diagnosis through surgery to illustrate how EUS and EUS-guided FNA influenced the treatment plan. Discussion focuses on rectal cancer and the importance of early detection through routine screening. The internationally accepted Tumor Node Metastasis (TNM) staging classification system for rectal cancer is included, followed by a description of EUS and EUS-guided FNA with regard to accuracy in staging. In conclusion, the various stage-dependent treatment options available for rectal cancer that can be individualized based on the patient's medical problems and preferences are discussed.

Gallbladder response to a second dose of cholecystokinin during the same imaging study.

Patients on total parenteral nutrition or after prolonged fasting may require treatment with cholecystokinin (CCK) prior to hepatobiliary imaging. Some may also require evaluation of gallbladder (GB) contractility, and the need for a second dose of CCK may arise. It is not clear whether gallbladder function can be adequately evaluated with CCK when a previous CCK dose had already been administered. We studied ten normal subjects to evaluate GB response to a second CCK injection. The subjects received 20 micrograms/kg sincalide in a 3-min infusion prior to administration of technetium-99m disofenin. They then received an identical sincalide dose at 60 min postinjection, and imaging was continued for another 30 min to quantify GB contraction. Gallbladder ejection fraction (GBEF) values ranged from 42-98% (mean: 71.5 +/- 19%). Pretreatment with CCK does not preclude GB contraction evaluation with a second dose of CCK. Expected GBEF values are similar to those obtained with single CCK injections.

Prevention of pancreatic cancer and strategies for management of familial pancreatic cancer.

At the current time, pancreatic cancer remains a difficult and typically fatal disease. A number of case reports and case-control epidemiologic studies have suggested that familial aggregation plays a role in as many as 10% of all pancreatic cancers. During the last several years, genetic alterations responsible for syndromes linked with pancreatic cancer have been identified. These genes include BRCA2, p16, PRSS1, STK11, and various mismatch repair genes. Unfortunately, most kindreds with a familial aggregation cannot be explained by one of these known genetic syndromes. Recent data from the National Familial Pancreas Tumor Registry at Johns Hopkins have estimated the prospective risk of pancreatic cancer among first-degree relatives of pancreatic cancer patients. The risk was estimated by comparing observed new cases of pancreatic cancer to expected numbers. In families where three first-degree relatives had been diagnosed with pancreatic cancer, the risk of another individual developing pancreatic cancer rose to a 57-fold increase over the basal risk. This article reviews the data concerning familial pancreatic cancer. Additionally, this article reviews the data concerning the histological precursors of invasive ductal adenocarcinoma of the pancreas: pancreatic intraepithelial neoplasias. Further, the current Johns Hopkins methodology used to screen for early pancreatic neoplasia in familial pancreatic cancer patients and in patients with familial Peutz-Jeghers syndrome is discussed. In summary, the notable advances in the field of molecular genetics have allowed for a better definition of the genetics of pancreatic cancer. With this knowledge has evolved a better understanding of several high-risk clinical syndromes associated with pancreatic cancer, familial pancreatic cancer, and the evolution of strategies to screen high-risk families for early pancreatic neoplasia.

Enteroscopy for the initial evaluation of iron deficiency.

BACKGROUND: Occult gastrointestinal blood loss is generally investigated with colonoscopy and esophagogastroduodenoscopy in patients with iron-deficiency anemia. The aim of this study was to prospectively measure the additional diagnostic yield of examining the jejunum at the time of upper endoscopy in patients with iron-deficiency anemia. METHODS: Asymptomatic patients with newly diagnosed iron-deficiency anemia who had no identifiable source of blood loss at colonoscopy underwent standard esophagogastroduodenoscopy with the Olympus SIF100L enteroscope followed by overtube-assisted enteroscopy. Upper tract and jejunal sources of blood loss were noted. Biopsy samples from the small bowel were taken when a bleeding lesion was not identified. RESULTS: Thirty-one consecutive patients (13 men, mean age 71) with no gastrointestinal symptomatology were studied. Eleven patients (35%) had a bleeding source that required only esophagogastroduodenoscopy for identification; 8 patients (26%) had a source only in the jejunum; 2 patients (6%) (one with sprue) had a source in upper tract as well as jejunum. The enteroscopy was rated as causing minimal or mild discomfort in 25 of 31 patients (81%). Using Medicare reimbursement figures, a strategy of performing esophagogastroduodenoscopy first would have cost $656 per patient, whereas the strategy of performing esophagogastroduodenoscopy with enteroscopy as the initial test in all patients costs $467 per patient. CONCLUSIONS: Performance of push enteroscopy along with esophagogastroduodenoscopy increases the diagnostic yield from 41% to 67% when evaluating the upper gastrointestinal tract of asymptomatic patients with iron-deficiency anemia and, because of a lower cost, should be the preferred initial diagnostic test.

Endoscopic ultrasonography versus cholangiography for the diagnosis of choledocholithiasis.

BACKGROUND: Choledocholithiasis is a major source of morbidity among patients undergoing cholecystectomy for symptomatic gallstones. There is no consensus on the best approach to diagnosing bile duct stones. We compared the safety, accuracy, diagnostic yield, and cost of EUS- and ERCP-based approaches. METHODS: Sixty-four consecutive pre- and post-cholecystectomy patients referred for endoscopic retrograde cholangiopancreatography (ERCP) for suspected choledocholithiasis were prospectively evaluated in a blinded fashion. All were stratified into risk groups using predefined criteria. Endoscopic ultrasonography (EUS) and ERCP were sequentially performed by two endoscopists. RESULTS: The success rates of EUS and ERCP were 98% and 94%, respectively. The accuracy of EUS for diagnosing choledocholithiasis was 94%. EUS provided an additional or alternative diagnosis to bile duct stones in 21% of patients. The complication rate of EUS was significantly lower than diagnostic ERCP. An EUS-based strategy costs less than diagnostic ERCP in patients with low, moderate, or intermediate risk. CONCLUSIONS: EUS is comparably accurate, but safer and less costly than ERCP for evaluating patients with suspected choledocholithiasis. It is useful in patients with an increased risk of having common bile duct stones based on clinical criteria and those with contraindications for or prior unsuccessful ERCP. EUS may enable selective performance of ERCP and improve the cost-effectiveness of diagnosing choledocholithiasis.

Management of Barrett's esophagus: a national study of practice patterns and their cost implications.

OBJECTIVE: The optimal management of Barrett's esophagus (BE) is controversial. Little is known about current practice patterns or associated direct medical costs. METHODS: In a national cross-sectional survey, we asked a random sample of gastroenterologists how they would manage patients with BE and various degrees of dysplasia. We used logistic regression to identify factors associated with so-called "frequent" (at least every 12 months) surveillance. We calculated direct medical costs using Medicare payments and population-based estimates of the number of BE patients under surveillance. RESULTS: Approximately 50% of 555 gastroenterologists responded. More than 96% of respondents recommended endoscopic surveillance for BE. For BE without dysplasia, 30% would perform frequent surveillance; this was the case particularly gastroenterologists older than age 45 yr (odds ratio = 1.91, p = 0.038) or those receiving primarily fee-for-service reimbursement (odds ratio = 2.57, p = 0.004). For BE with low-grade dysplasia, the frequency of endoscopy was highly variable (range, 1-24 months). For BE with high-grade dysplasia, 73% of gastroenterologists recommended esophagectomy and the remainder recommended endoscopic surveillance. Approximately 95% of the gastroenterologists who recommended surveillance for high-grade dysplasia, however, were not in agreement with recommended protocols. We estimated the national annual expenditure for surveillance endoscopy every 24 months for BE without dysplasia to be at least $22 million. Increase in surveillance intensity from low frequency (every 36 months) to high frequency (every 12 months) strategies would escalate costs by $29 million annually. CONCLUSIONS: Physician age and reimbursement influence BE surveillance practice, suggesting the influence of nonclinical factors on clinical decision making. The majority of clinicians who would recommend surveillance for high-grade dysplasia may not be using an appropriately aggressive strategy. Variations in surveillance strategies can have large cost implications.