Improving Adherence to Clinical Practice Guidelines for Managing Gastric Intestinal Metaplasia Among Gastroenterologists at a US Academic Institution.

BACKGROUND: Clinical guidelines reserve endoscopic surveillance after a gastric intestinal metaplasia (GIM) diagnosis for high-risk patients. However, it is unclear how closely guidelines are followed in clinical practice. We examined the effectiveness of a standardized protocol for the management of GIM among gastroenterologists at a US hospital. METHODS: This was a preintervention and postintervention study, which included developing a protocol and education of gastroenterologists on GIM management. For the preintervention study, 50 patients with GIM were randomly selected from a histopathology database at the Houston VA Hospital between January 2016 and December 2019. For the postintervention study, we assessed change in GIM management in a cohort of 50 patients with GIM between April 2020 and January 2021 and surveyed 10 gastroenterologists. The durability of the intervention was assessed in a cohort of 50 GIM patients diagnosed between April 2021 and July 2021. RESULTS: In the preintervention cohort, GIM location was specified (antrum and corpus separated) in 11 patients (22%), and Helicobacter pylori testing was recommended in 11 of 26 patients (42%) without previous testing. Gastric mapping biopsies were recommended in 14% and surveillance endoscopy in 2%. In the postintervention cohort, gastric biopsy location was specified in 45 patients (90%, P <0.001) and H. pylori testing was recommended in 26 of 27 patients without prior testing (96%, P <0.001). Because gastric biopsy location was known in 90% of patients ( P <0.001), gastric mapping was not necessary, and surveillance endoscopy was recommended in 42% ( P <0.001). One year after the intervention, all metrics remained elevated compared with the preintervention cohort. CONCLUSIONS: GIM management guidelines are not consistently followed. A protocol for GIM management and education of gastroenterologists increased adherence to H. pylori testing and GIM surveillance recommendations.

Building a Quality Practice in Chronic Pancreatitis.

Chronic pancreatitis (CP) is a fibroinflammatory disorder that results in irreversible scarring to pancreatic parenchyma and presents with a myriad of symptoms including abdominal pain, nausea, weight loss, steatorrhea, and diabetes. Furthermore, patients with CP often have comorbid chemical dependencies to alcohol and tobacco, which can further complicate the management of CP. Recent literature proposes guidelines on how best to care for patients with CP and establishes requirements for centers of excellence. Here, we review the available data on endoscopic therapies, pain management, chemical dependency, and nutrition for patients with CP and propose quality metrics that may be used to establish a quality practice.

Prevalence and Predictors of Missed Dysplasia on Index Barrett's Esophagus Diagnosing Endoscopy in a Veteran Population.

BACKGROUND & AIMS: Limitations of endoscopic sampling may result in missed dysplasia at the diagnosis of Barrett's esophagus (BE). However, the role of close follow-up endoscopy is unclear. The aim was to evaluate the proportion of patients diagnosed with "missed" dysplasia within 18 months of their index nondysplastic BE (NDBE) diagnosis. METHODS: This was a retrospective analysis of a cohort of BE patients diagnosed during 1990-2019 at the Houston VA. Patients with BE on index esophagogastroduodenoscopy (EGD) were classified as NDBE, indefinite dysplasia, or dysplastic (low- or high-grade dysplasia) based on initial biopsies. We identified NDBE patients who had follow-up EGD within 3-18 months after index EGD. We used logistic regression models to estimate odds ratios and 95% confidence intervals for risk factors of dysplasia on follow-up EGD. RESULTS: We identified 614 patients who had BE on index EGD. Among those with NDBE and follow-up EGD within 3-18 months (n = 271), 4.1% had definite dysplasia on follow-up, and an additional 14.0% had indefinite dysplasia. Proportions of definite or indefinite dysplasia at follow-up within 3-18 months significantly decreased from 32.6% among patients with index EGD before 2009 to 11.7% among patients with index EGD after 2013 (P for trend = .068). Those with any indefinite or definite dysplastic BE at follow-up within 3-18 months after index EGD (n = 49) were more likely to have BE length ≥3 cm on index EGD (odds ratio, 3.39; 95% confidence interval, 1.63-7.08) than those with persistent NDBE or no BE on follow-up. CONCLUSIONS: The occurrence of missed dysplasia on an index EGD has decreased over time. However, those with long segment BE were more than 3 times as likely to have missed dysplasia, and this group could benefit from dysplasia surveillance within 18 months of BE diagnosis.

External validation of a model determining risk of neoplastic progression of Barrett's esophagus in a cohort of U.S. veterans.

BACKGROUND AND AIMS: Risk of esophageal adenocarcinoma (EAC) in those with Barrett's esophagus (BE) is 11-fold greater than the general population. It remains unclear which BE patients are at highest risk of progression to EAC. We aimed to validate a predictive model risk-stratifying BE patients. METHODS: We conducted a retrospective cohort study at the Houston Veteran Affairs Medical Center of consecutive patients with a new diagnosis of BE from November 1990 to January 2019. Study follow-up was through February 2020. Patients were excluded if they had no follow-up EGD with esophageal biopsy sampling after the initial BE-diagnosing EGD or evidence of high-grade dysplasia (HGD) or EAC on initial EGD. We performed an external validation study of a risk model containing sex, smoking, BE length, and low-grade dysplasia (LGD) status and assessed discriminatory ability using the area under the receiver operating characteristic curve (AUROC). RESULTS: Among 608 BE patients, 24 progressed to HGD/EAC. The points-based model discriminated well with an AUROC of .72 (95% confidence interval [CI], .63-.82). When categorized into low-, intermediate-, and high-risk groups according to published cutoffs, the AUROC was poor at .57. Restructured into low-risk versus high-risk groups, the AUROC was .72 (95% CI, .64-.80). Excluding baseline LGD did not reduce discriminatory ability (AUROC, .73; 95% CI, .64-.82). CONCLUSIONS: This external validation provides further evidence that the model including sex, LGD status, smoking status, and BE length may help to risk stratify BE patients. A simplified version excluding LGD status and/or reducing the number of risk groups has increased utility in clinical practice without loss of discriminatory ability.

Spatial Characteristics of Colonic Mucosa-Associated Gut Microbiota in Humans.

Limited data exist on the spatial distribution of the colonic bacteria in humans. We collected the colonic biopsies from five segments of 27 polyp-free adults and collected feces from 13 of them. We sequenced the V4 region of the bacterial 16S rRNA gene using the MiSeq platform. The sequencing data were assigned to the amplicon sequence variant (ASV) using SILVA. Biodiversity and the relative abundance of the ASV were compared across the colonic segments and between the rectal and fecal samples. Bacterial functional capacity was assessed using Tax4fun. Each individual had a unique bacterial community composition (Weighted Bray-Curtis P value = 0.001). There were no significant differences in richness, evenness, community composition, and the taxonomic structure across the colon segments in all the samples. Firmicutes (47%), Bacteroidetes (39%), and Proteobacteria (6%) were the major phyla in all segments, followed by Verrucomicrobia, Fusobacteria, Desulfobacterota, and Actinobacteria. There were 15 genera with relative abundance > 1%, including Bacteroides, Faecalibacterium, Escherichia/Shigella, Sutterella, Akkermansia, Parabacteroides, Prevotella, Lachnoclostridium, Alistipes, Fusobacterium, Erysipelatoclostridium, and four Lachnospiraceae family members. Intra-individually, the community compositional dissimilarity was the greatest between the cecum and the rectum. There were significant differences in biodiversity and the taxonomic structure between the rectal and fecal bacteria. The bacterial community composition and structure were homogeneous across the large intestine in adults. The inter-individual variability of the bacteria was greater than inter-segment variability. The rectal and fecal bacteria differed in the community composition and structure.

Accuracy of a novel noninvasive secretin-enhanced MRCP severity index scoring system for diagnosis of chronic pancreatitis: correlation with EUS-based Rosemont criteria.

PURPOSE: To evaluate the accuracy of a secretin-enhanced MRCP Chronic Pancreatitis Severity Index (CPSI) in the diagnosis of chronic pancreatitis (CP) based on endoscopic ultrasound (EUS) Rosemont criteria. METHODS: In this retrospective study, 31 patients (20 women; median age 48 years, range 18-77) with known/suspected CP evaluated with both EUS and secretin-enhanced MRCP were included. CP severity was graded using a ten-point-scale secretin-enhanced MRCP-based CPSI scoring system which considered ductal, parenchymal and secretin-based dynamic abnormalities. Cases were categorized as normal, mild, moderate or severe CP. Correlation between CPSI and the EUS Rosemont criteria was performed using Cohen's kappa coefficient. Comparative evaluation of test performance was obtained using ROC analysis. RESULTS: Using EUS Rosemont criteria, eight patients had features consistent/suggestive of CP, 20 patients were normal and three were indeterminate. On CPSI, five patients were normal, 12 had mild and 14 had moderate/severe CP. There was only fair agreement (k = 0.272) between CPSI and Rosemont criteria categories. CPSI showed 87.5% sensitivity, 69.6% specificity and 74.2% accuracy (cutoff value = 3.5 points; area under the curve = 0.804; p = 0.0026) for CP diagnosis based on EUS Rosemont criteria. CONCLUSION: CPSI showed relatively high diagnostic accuracy for diagnosis of CP based on Rosemont criteria. The CPSI scoring system can be proposed as a noninvasive alternative to the EUS Rosemont criteria for CP diagnosis.

Scope of Burnout Among Young Gastroenterologists and Practical Solutions from Gastroenterology and Other Disciplines.

Burnout is a critical issue among physicians, including gastroenterologists. Up to 50% of gastroenterologists have reported symptoms of burnout in national assessments, leading to increased recognition of the burden of burnout among subspecialty societies. Particularly alarming in these assessments of burnout is the suggestion of increased rates of burnout among trainees and early career gastroenterologists. In this article, we describe the scope of burnout among young gastroenterologists and the risk factors that contribute. In addition, we will offer practical solutions to reduce burnout based on insights developed from multidisciplinary approaches, including relevant burnout literature, organizational approaches within academic medical centers, and training programs, as well as interviews with successful private practice gastroenterologists, and leaders in the fields of business and education.

Quality of Care Indicators in Patients with Acute Pancreatitis.

BACKGROUND: Acute pancreatitis (AP) is a common and expensive condition. Improving quality of care in AP is vital to minimizing cost and improving patient outcomes. However, there has been little work accomplished toward developing and validating explicit quality indicators (QIs) in AP. AIMS: To define quality of care in patients with AP by developing explicit QIs using standardized techniques. METHODS: We used the UCLA/RAND Delphi panel approach to combine a comprehensive literature review with the collective judgment of experts to identify a defined set of process measures for AP. RESULTS: We produced 164 candidate QIs after a comprehensive literature review. After Delphi review, 75 had a median rating ≥ 7. We excluded 11 QIs where the disagreement index exceeded 1.0 and combined indicators overlapping in content to produce a final list of 22 QIs. Overall, 8 QIs related to diagnosis, prevention, or determination of etiology, 2 QIs focused on determination of severity, 3 QIs captured fluid resuscitation, 2 QIs measured nutrition, 1 QI use of antibiotics, and 6 QIs captured endoscopic or surgical management. CONCLUSIONS: We have developed 22 QIs spanning the spectrum of AP management including diagnosis, risk stratification, and pharmacological and endoscopic therapy. These QIs will facilitate future quality improvement by practitioners and organizations who treat patients with AP and further identify areas that are amenable to improvement to enhance patient care. We anticipate that this QI set will represent the first step in determining a framework for demonstrating value in the care of patients with AP.

Rational Use of Pancreatic Enzymes for Pancreatic Insufficiency and Pancreatic Pain.

We describe the rational use of enteric coated and unprotected replacement pancreatic enzymes for treatment of malabsorption due to pancreatic insufficiency and for pancreatic pain. Enteric coated formulations mix poorly with food allowing separation of enzymes and nutrients when emptying from the stomach. The site of dissolution of the enteric coating in the intestine is also unpredictable and enzymes may not be released until the distal intestine. Together, these barriers result in the lack of dose-response such that the strategy of increasing the dosage following a suboptimal effect is often ineffective. The ability to maintain the intragastric pH ≥4 with the combination of proton pump inhibitors and antacids suggests that it should be possible to reliably obtain a good response with uncoated enzymes. We also discuss the recognition, treatment and prevention of nutritional deficiencies associated with pancreatic insufficiency and recommend a test and treat strategy to identify and resolve nutritional deficits. Finally, we focus on mechanisms causing pain that may be amenable to therapy with pancreatic enzymes. Pain due to malabsorbed digestive contents can be prevented by successful therapy of malabsorption. Feedback inhibition of endogenous pancreatic secretion can prevent pain associated with pancreatic secretion but requires use of non-enteric coated formulations.

High Glasgow Blatchford Score at admission is associated with recurrent bleeding after discharge for patients hospitalized with upper gastrointestinal bleeding.

BACKGROUND AND STUDY AIMS: Upper gastrointestinal bleeding (UGIB) is associated with significant morbidity. The Glasgow Blatchford Score (GBS) can predict endoscopic intervention and in-hospital death, but the ability to predict post-discharge outcomes is unknown. The aims of the study were to determine whether the admission GBS is associated with post-discharge rebleeding and 30-day readmission following hospitalization for UGIB. PATIENTS AND METHODS: In this prospective, observational, cohort study, consecutive patients who were hospitalized with UGIB were enrolled. Admission GBS scores were calculated, and patients with GBS > 7 were classified as high risk. Patients were contacted 30 days following discharge to determine: 1) rate of hospital readmission due to rebleeding, 2) all-cause readmissions, and 3) mortality. Multivariable Cox regression was used to determine associations between GBS, rebleeding, and readmission. RESULTS: A total of 336 patients with UGIB were identified. Patients with high risk GBS were older (68 vs. 62 years; P = 0.01), and were more likely to receive blood (85 % vs. 39 %; P < 0.01) and require intensive care unit admission (64 % vs. 50 %; P = 0.02). Of the 309 patients who survived to discharge, 61 (20 %) were readmitted within 30 days, 25 (8 %) of whom had rebleeding. On multivariable analysis adjusting for the need for endoscopic intervention, high risk GBS patients had higher rebleeding rates (hazard ratio [HR] 3.32, 95 % confidence interval [CI] 1.26 - 11.4). On multivariable analysis, patients with more co-morbidities (HR 1.06, 95 %CI 1.01 - 1.11) and cirrhosis (HR 2.23, 95 %CI 1.19 - 4.04) had higher 30-day readmission rates. CONCLUSIONS: High GBS scores were associated with higher rebleeding rates following discharge. Patients with high GBS scores (> 7) should be monitored following discharge as they have a high risk of rebleeding.

Localizing Acute Lower Gastrointestinal Hemorrhage: CT Angiography Versus Tagged RBC Scintigraphy.

OBJECTIVE: Lower gastrointestinal hemorrhage is a common cause of hospitalization and has substantial associated morbidity and financial cost. CT angiography (CTA) is emerging as an alternative to (99m)Tc-labeled RBC scintigraphy (RBC scintigraphy) for the localization of acute lower gastrointestinal bleeding (LGIB); however, data on comparative efficacy are scant. The aim of this study was to assess the utility of CTA compared with RBC scintigraphy in the overall evaluation and management of acute LGIB. MATERIALS AND METHODS: We retrospectively reviewed images from all CTA examinations performed for suspected acute LGIB at our tertiary care hospital from January 2010 through November 2011. The comparison group was determined by retrospective review of twice the number of RBC scintigraphic scans consecutively obtained from June 2008 to November 2011 for the same indication. All CTA and RBC scintigraphic scans were reviewed for accurate localization of the site and source of suspected active LGIB. RESULTS: In total, 45 CTA and 90 RBC scintigraphic examinations were performed during the study period. Seventeen (38%) CTA scans showed active gastrointestinal bleeding compared with 34 (38%) RBC scintigraphic scans (p = 1.000). However, the site of bleeding was accurately localized on 24 (53%) CTA scans. This proportion was significantly greater than the proportion localized on RBC scintigraphic scans (27 [30%]) (p = 0.008). There were no significant differences between the two groups in average hospital length of stay, blood transfusion requirement, incidence of acute kidney injury, or in-hospital mortality. CONCLUSION: Both CTA and RBC scintigraphy can be used to identify active bleeding in 38% of cases. However, the site of bleeding is localized with CTA in a significantly higher proportion of studies.

The Use of Standard Gastrointestinal Endoscopic Ultrasound to Assess Cardiac Anatomy.

In this prospective observational study, conducted at an academic medical center, we evaluated the feasibility of performing a basic transesophageal echocardiography (TEE) examination using endoscopic ultrasound (EUS) technology to determine what cardiac structures could be assessed. This may be potentially beneficial during hemodynamic emergencies in the endoscopy suite resulting from hypovolemia, depressed ventricular function, aortic dissection, pericardial effusions, or aortic stenosis. Of the 20 patients enrolled, 18 underwent EUS with a linear echoendoscope for standard clinical indications followed by a cardiac assessment performed under the guidance of a TEE-certified cardiac anesthesiologist. Eight of the 20 standard views of cardiovascular structures per the 1999 American Society of Echocardiography/Society of Cardiovascular Anesthesiologists guidelines for TEE could be obtained using the linear echoendoscope. The following cardiac valvular structures were visualized: aortic valve (100%), mitral valve (100%), tricuspid valve (33%), and pulmonic valve (11%). Left ventricular and right ventricular systolic function could be assessed in 89% and 67% of patients, respectively. Other structures such as the ascending and descending aorta, pericardium, left atrial appendage, and interatrial septum were identified in 100% of patients. Doppler-dependent functions could not be assessed. Given that the EUS images were not directly compared with TEE in these patients, we cannot comment definitively on the quality of these assessments and further studies would need to be performed to make a formal comparison. Based on this study, EUS technology can consistently assess the mitral valve, aortic valve, aorta, pericardium, and left ventricular function. Given its limitations, EUS technology, although not a substitute for formal echocardiography, could be a helpful early diagnostic tool in an emergency setting.

Quality measures and quality improvements in colonoscopy.

PURPOSE OF REVIEW: Approximately 14 million colonoscopies are performed annually in the United States making this the most common gastrointestinal endoscopic procedure. Although the demand for colonoscopy remains strong, improvements in fecal DNA technology and computed tomography colonography now compete with colonoscopy as viable colon cancer screening alternatives. Increasing costs of providing healthcare have renewed the focus on the value of medical services. For colonoscopy to remain the dominant colon cancer screening strategy, it is imperative that we continue to measure and improve the quality of colonoscopy. The purpose of this article is to discuss quality measures and quality improvement in colonoscopy. RECENT FINDINGS: We describe recent advances in five prominent quality measures: cecal intubation rate, adherence to recommended screening and surveillance interval, adenoma detection rate, quality of bowel preparation, and colonoscopy withdrawal time. SUMMARY: Quality measures should be used by endoscopists to document and compare their performance with recommended benchmarks. Quality-improvement programmes can then be developed and targeted towards areas of deficiency.

Salvage cryotherapy after failed radiofrequency ablation for Barrett's esophagus-related dysplasia is safe and effective.

BACKGROUND: Radiofrequency ablation (RFA) is an effective treatment for Barrett's esophagus (BE) dysplasia. For patients with dysplasia refractory to RFA, data are limited regarding efficacy of endoscopic therapy. OBJECTIVE: To assess the efficacy and safety of cryotherapy in patients with BE dysplasia who failed RFA. DESIGN: Single-center, retrospective, cohort study. SETTING: Tertiary-care center between 2006 and 2013. PATIENTS: Patients with BE and low-grade dysplasia (LGD), high-grade dysplasia (HGD), or intramucosal carcinoma (IMC) were referred for RFA every 2 to 3 months. Response was determined by complete eradication of dysplasia (CE-D). INTERVENTIONS: Patients without CE-D or those with recurrent dysplasia after initial eradication were offered cryotherapy. MAIN OUTCOME MEASUREMENTS: Eradication of dysplasia and/or cancer. Secondary outcome, eradication of intestinal metaplasia. RESULTS: A total of 121 patients underwent RFA for BE dysplasia (55% HGD, 26% LGD, 17% IMC, 2% indefinite dysplasia). After a median of 3 RFA sessions, 75% (n = 91) had CE-D. Patients without CE-D were more likely to have a longer BE length (7 cm vs 4 cm; P = .004) and a hiatal hernia (83% vs 55%; P = .005). Sixteen patients (14 with failed CE-D and 2 with recurrent dysplasia) were offered cryotherapy and had endoscopic follow-up. Seven (57%) had HGD before cryotherapy (6 with LGD, 2 with IMC, and 1 with indefinite dysplasia). After cryotherapy, 12 (75%) had CE-D, and 5 (31%) had eradication of intestinal metaplasia. Of patients with IMC, 100% had CE-D. Three patients developed strictures that responded to dilation. LIMITATIONS: Single center, retrospective nature of study. CONCLUSION: For patients with refractory dysplasia or recurrent dysplasia after RFA, salvage cryotherapy is a safe and effective endoscopic therapy.