Technical Success in Performing Esophageal High-Resolution Manometry in Patients with an Epiphrenic Diverticulum.

High-resolution manometry (HRM) is the gold standard for diagnosing esophageal motility disorders, yet it can be poorly tolerated and technically challenging. Epiphrenic diverticula (ED) are located in the distal esophagus and are associated with underlying motility disorders. ED patients (2008-2022) were retrospectively compared to achalasia patients (2008-2022) and all other patients (2021-2022) who underwent HRM at a single center. Complete success was defined as at least 7 interpretable swallows including measurements throughout the esophagus into the stomach. HRM studies involving children, previously treated achalasia, and sedation or endoscopic-assistance were excluded. 20 ED patients (mean age 66; 60% female) were compared to 76 achalasia patients and 199 controls. HRM was completely successful in 70.0% of ED patients, 85.5% of achalasia (p = 0.106 vs ED), and 91.0% of controls (p = 0.004 vs ED). Most failures in the ED and achalasia groups were due to inability to traverse the esophagogastric junction (EGJ), while patient intolerance was the main reason in controls. Half of the ED group had motility disorders (25% achalasia, 15% hypercontractile esophagus, 10% absent contractility). Large diverticulum size was inversely associated with technical success compared to small diverticulum size (40% vs 100%, p = 0.013), while the presence of a motility disorder did not significantly affect success (60% vs 88.9%, p = 0.303). In conclusion, ED is a predictor of unsuccessful HRM. This appears to be mainly related to an inability to traverse the EGJ due to the size of the diverticulum. Consideration should be given to alternative means of evaluating motility, such as endoscopy-assisted HRM, given the high likelihood of failure with traditional HRM.

Proton pump inhibitors in eosinophilic esophagitis (EoE) related to oral immunotherapy: is it as effective as in other EoE?

Oral immunotherapy (OIT) may induce eosinophilic esophagitis (EoE). Proton pump inhibitors (PPIs) are an effective treatment for EoE. However, the effect of PPI treatment is not well established in patients with EoE induced by OIT. Our primary aim was to compare the clinical, endoscopic, and histological response rates to PPIs in children with EoE induced by OIT (EoE+OIT) versus EoE patients without OIT (EoE-OIT). The secondary aims are to describe the clinical and histological features of EoE+OIT. Demographic, clinical, endoscopic, and histological findings of patients with EoE in the gastroenterology clinic at Shamir Medical Center between March 2015 and December 2022 were collected. Comparisons were performed between EoE+OIT and EoE-OIT patients. The study included 42 children (74% male, mean age 11.2), of whom 31 had EoE-OIT and 11 had EoE+OIT. There were no significant differences between groups regarding sex, comorbidities, symptoms, or endoscopic and histological characteristics at diagnosis. All 42 children were treated with PPIs after diagnosis with or without diet changes. The rates of any clinical response were 83.9% and 90.1% in the EoE-OIT group and EoE+OIT group, respectively (p = 1.0). The rate of any endoscopic response was 74.2% for EoE-OIT and 81.8% for EoE+OIT (p = 0.54). Histologically, PPIs were even more effective in the EoE+OIT group, where only 18.2% had no histological response at all compared to 51.6% in the EoE-OIT group (p = 0.1). CONCLUSION: PPI treatment is as effective in EoE with OIT as it is in EoE due to other etiologies. WHAT IS KNOWN: • Proton pump inhibitor (PPI) treatment is effective for achieving clinical response and histologic remission in some patients with eosinophilic esophagitis (EoE). • EoE has also been reported to be triggered by oral immunotherapy (OIT). WHAT IS NEW: • PPI treatment in EoE with OIT is as effective as treatment for EoE due to other etiologies.

Technical success in performing esophageal high-resolution manometry: a review of competency recommendations, predictors of failure, and alternative techniques.

Esophageal high-resolution manometry (HRM) is the gold standard for diagnosing esophageal motility disorders. As this is performed without sedation, it may be poorly tolerated by patients. Additionally, advancing the catheter tip until the stomach may also be difficult, especially if there is a disease affecting the esophagus or esophagogastric junction which may lead to coiling of the catheter. Currently, there are no guidelines as to who can perform HRM. An expert opinion has recommended minimum numbers of cases for the operator to perform in order to obtain and maintain competency. Several studies have reported on the rates of flawed HRM studies with approximately 20% being imperfect, including about 3% with critical flaws. The presence of a large hiatal hernia and achalasia have been identified as predictors of technical failure. Studies with minor flaws are usually still interpretable and clinically useful. Reports have also described several techniques for sedation-assisted placement of the HRM catheter, and this appears to be a promising alternative in cases of failed HRM, especially as sedation does not appear to significantly affect HRM measurements. An algorithm on how to proceed after a technically imperfect HRM study is proposed. Further research in this field is warranted including confirmation of the recommended competency numbers, assessing for quality measures in performing HRM such as technical success rate, identifying additional predictors of technical failure, standardization of the terminology, and qualifying the benefit of sedation-assisted HRM.

Chicago Classification Version 4.0 Improves Stratification of Ineffective Esophageal Motility Patients into Clinically Meaningful Subtypes: A Two-Center International Study.

The 4th iteration of the Chicago Classification (CC v4.0) for esophageal motility disorders offers more restrictive criteria for the diagnosis of Ineffective Esophageal Motility (IEM) compared to version 3.0 (CC v3.0). In light of the updated criteria for IEM, we aimed to characterize and compare the patients who retained their IEM diagnosis to those who were reclassified as normal motility, and to evaluate the clinical impact of the newly introduced CC v4.0. We performed a retrospective case-control study. We included all individuals who underwent a high-resolution manometry (HRM) between 2020 and 2021 at two centers. Consecutive studies reported as IEM according to the CC v3.0 were reanalyzed according to the CC v4.0. We compared demographics, clinical, manometry, and pH-monitoring parameters. Out of 452 manometry studies, 154 (34%) met criteria for IEM as per the CC v3.0 (CC v3.0 IEM group). Of those, 39 (25%) studies were reclassified as normal studies according to the CC v4.0 (CC v4.0 normal group), while the remaining 115 studies (25% of the overall cohort) retained an IEM diagnosis (CC v4.0 IEM group). The CC v4.0 normal group had more recovered contractions during solid swallows (p = 0.01), less ineffective swallows (p = 0.04), and lower acid exposure time (p = 0.02) compared to the CC4.0 IEM group. Under CC v4.0 criteria, fewer patients are diagnosed with IEM. Those diagnosed with IEM had worse esophageal function and higher acid burden. Though further studies are needed to confirm these findings, our results indicate that CC v4.0 criteria restrict the IEM diagnosis to a more clinically meaningful population.

Ethnic Differences in Clinical Presentations and Esophageal High-Resolution Manometry Findings in Patients with Achalasia.

BACKGROUND: Ethnic differences in achalasia presentations have scarcely been described. The association between achalasia and immunologic HLA haplotypes suggests that there may be a genetic predisposition. We aimed to evaluate differences in demographic, clinical, endoscopic, and manometric findings between two distinct ethnic groups with achalasia-Israeli Arabs (IA) and Israeli Jews (IJ). METHODS: A retrospective study was performed at two medical centers. High-resolution manometry (HRM) reports were reviewed for newly-diagnosed achalasia patients. Demographic data, clinical presentations, endoscopy reports, and HRM metrics including the integrated relaxation pressure (IRP) were all reviewed. RESULTS: Overall, 94 achalasia patients were included (53.2% male; mean age 54.5 ± 18.0). 43 patients were IA (45.7%). Body mass index (BMI) was similar in both groups. Compared to IJ, the IA patients had more esophageal dysphagia (100% vs. 88.2%; P = 0.022), chest pain (46.5% vs. 25.5%; P = 0.033), and a tortuous esophagus on endoscopy (23.3% vs. 3.9%; p = 0.005). IA patients were also diagnosed at a younger age than IJ patients (50.9 ± 17.5 vs. 57.5 ± 18.0; p = 0.039). Furthermore, IRP values were higher among IA patients than IJ patients (32.2 ± 13.8 vs. 23.3 ± 8.4; p < 0.001). A regression model analysis found that ethnicity significantly predicted IRP (ß = - 10, p < .001). CONCLUSION: Ethnicity appears to affect achalasia clinical presentation and HRM findings. IA achalasia patients are diagnosed at a younger age, present with more severe esophageal symptoms, and have a higher IRP compared to IJ patients. Additional studies of diverse, multiethnic populations, especially with genetic evaluations, are required to further assess the role of ethnicity in achalasia.

Predictors of Underlying Esophageal Motility Disorders in Patients Presenting with Esophageal Candidiasis.

OBJECTIVES: Esophageal motility disorders (EMDs) are a known risk factor for esophageal candidiasis (EC), but this relation has not been described particularly well. We sought to evaluate the predictors of underlying EMDs in patients presenting with EC. METHODS: Cases of EC at a single medical center between 2010 and 2021 were identified retrospectively based on the International Classification of Diseases, Ninth Revision code. Demographic, clinical, endoscopic, and manometric data were reviewed. The diagnosis of EC was based on typical endoscopic appearance. RESULTS: In total, 130 EC patients were identified (mean age 69.5 ± 14.6; 66.2% male). Of these, 12 (9.2%) had an underlying EMD (11 cases of achalasia; 1 case of esophagogastric junction outflow obstruction). Five (41.7%) of these patients had previously been diagnosed as having an EMD, whereas 7 were newly diagnosed only after their presentation with EC. No significant differences were noted between those with or without EMDs in terms of demographics, medical comorbidities, or medication use. Patients with an EMD, however, were more likely to complain of dysphagia (91.7% vs 30.5%, P < 0.001), and on endoscopy, they were more likely to have residual food in the esophagus, residual fluid in the esophagus, a dilated esophagus, and resistance to traversing the esophagogastric junction (all P < 0.001). Sixty-one (46.9%) patients with EC died during follow-up (mean 58 months). CONCLUSIONS: EMDs are present in approximately 10% of patients presenting with EC, with half being diagnosed only after presenting with EC. Similar to non-EC patients, patients with EC with dysphagia and the typical endoscopic findings of achalasia are more likely to have an EMD and warrant prompt manometric evaluation.

Factors Associated With Adherence to a Gluten-Free Diet in Celiac Patients Diagnosed in Childhood as Compared to Adulthood.

Past studies have reported differences between pediatric and adult celiac disease patients. We aimed to compare factors associated with adherence to a gluten-free diet between these groups. An anonymous online questionnaire was sent via the Israeli Celiac Association and social networks to celiac patients. The Biagi questionnaire was used to assess dietary adherence. A total of 445 subjects participated. Mean age was 25.7 ± 17.5 years and 71.9% were female. Subjects were divided into six groups according to age at diagnosis: younger than 6 years (134 patients, 30.7%), 6-12 (79 patients, 18.1%), 12-18 (41 patients, 9.4%), 18-30 (81 patients, 18.5%), 30-45 (79 patients, 18.1%), and 45 years and above (23 patients, 5.3%). There were several significant differences between childhood- and adulthood-diagnosed patients. Pediatric patients were less likely to be noncompliant with a gluten-free diet (3.7% vs. 9.4%, p < .001). They were also more frequently followed by a gastroenterologist ( p < .001), a dietitian ( p < .001), and participated in a celiac support group ( p = .002). In logistic regression analyses, longer duration of disease was associated with poor compliance. In conclusion, pediatric-diagnosed celiac patients are more adherent to a gluten-free diet than those diagnosed in adulthood, with better social support and nutritional follow-up possibly contributing.

The Perception among Israeli Gastroenterologists Regarding Treatment of Patients with Biosimilar Medications.

Background and Objectives: The ever-expanding entry of biosimilar drugs into the Israeli market requires doctors to decide whether to prescribe these medications. We aimed to assess the prevalence of biosimilar use and Israeli gastroenterologists' knowledge, experience, and perception of biosimilar treatment. Materials and Methods: A cross-sectional survey was conducted among Israeli Gastroenterology Association (IGA) members between March and May 2022 using a structured 20-item questionnaire. Results: The questionnaire was completed by 108 gastroenterologists. Sixty-two percent prescribed biosimilars to their patients in the past year. Most of the patients (81%) were biologically naïve and only 19% were switched to a biosimilar. Most gastroenterologists (75%) answered that the effectiveness is the same. The rates of resistance to switching were 19%, 36%, and 70% for patients in remission for over two years, pregnant women, and difficulty reaching remission, respectively. In cases seeing a lack of response after switching, most physicians chose to change the mechanism of action, with only a small percentage returning to the brand-name drug. Conclusions: Most Israeli gastroenterologists are not concerned about biosimilars' safety and efficacy. Despite this, most physicians will prefer the brand-name drug, especially regarding adalimumab. The populations in which physicians most oppose switching are those who have had difficulty achieving remission and pregnant women.

Video Capsule Endoscopy Has a Minor Long-term Therapeutic Impact on Patients with Iron Deficiency Anemia.

BACKGROUND: One of the main causes of iron deficiency anemia (IDA) is chronic gastrointestinal blood loss. The use of video capsule endoscopy (VCE) after negative bidirectional endoscopy in patients with IDA is controversial. OBJECTIVES: To evaluate the effect of VCE in the management and long-term outcomes of IDA patients. METHODS: A retrospective case-control study was performed on all patients with IDA undergoing VCE over a 5-year period. We compared those with positive findings on VCE to those with normal findings. All participants previously underwent a negative bidirectional endoscopy. RESULTS: We performed 199 VCE examinations; median follow-up time was 4 years (IQR 2-5). Positive findings were identified in 66 patients (diagnostic yield 33.2%). Double balloon enteroscopy or push enteroscopy was performed in eight patients (18.6%); only one was therapeutic. The main therapy in both groups was iron supplementation. There were no significant differences in iron treatment before and after VCE in each group and between groups. Anemia improved in both groups. There was no difference in the level of hemoglobin change between the groups during each year of follow-up compared to the baseline level prior to VCE. Anemia resolved in 15 patients (35%) in the positive VCE group and in 19 (45%) in the negative VCE group (P = 0.33). CONCLUSIONS: Positive findings on VCE led to subsequent endoscopic interventions only in a small percentage of patients with IDA. Anemia improved and resolved equally whether or not there were VCE findings. The main intervention that appears to help IDA is iron supplementation.

The Effect of a Didactic Course on Gastroenterology Nurses' Knowledge and Interest in Anorectal Manometry.

Anorectal manometry may be performed by a nurse or physician, yet little has been written about what training is needed. Additionally, many gastroenterology nurses receive little exposure to motility studies such as anorectal manometry, limiting their ability to learn these procedures. We therefore sought to evaluate whether a short didactic course on anorectal manometry would increase nurses' knowledge about the procedure and stimulate their interest in becoming trained to perform it. To accomplish this, gastroenterology nurses attended a series of three lectures on anorectal manometry. A 15-question quiz was given as a pre-test and again as a post-test after completing the course. Thirteen nurses participated (11 female, mean age 46). None had experience performing anorectal manometry. Due to the course, test scores increased from a mean of 8.4 (55.9%) correct to 13.3 (88.7%) (p < .001), with improvements noted in 12 of 13 participants (92.3%). All of the nurses felt that the course increased their knowledge of anorectal manometry and reported that they would recommend it to other nurses. Most (61.5%) also expressed an interest in becoming trained to perform anorectal manometry. In conclusion, a short didactic course has been shown to increase nurses' knowledge and interest in performing anorectal manometry.

Inflammatory Bowel Disease: Its Effects on Physical Activity, Sports Participation, and Athletes.

ABSTRACT: This article discusses the "bidirectional" relationship between inflammatory bowel disease (IBD) and physical activity. Intestinal symptoms and extraintestinal manifestations of IBD negatively impact a patient's ability to participate in sports. IBD also impacts athletic performance via its effects on muscle mass, muscle function, bone density, and fatigue. Surveys of IBD patients consistently show that IBD interferes with athletic participation. While IBD negatively affects physical activity, there is growing evidence that physical activity can be beneficial for IBD patients. Prospective studies have revealed that structured physical activities may positively influence inflammatory markers, disease activity, muscle strength, bone density, fatigue, stress, anxiety, and quality of life. This suggests that physical activity may be a simple and safe adjuvant therapy for IBD patients. Future studies assessing the optimal activity regimen are warranted. Finally, a cohort of professional athletes with IBD are described for the first time - football players in the National Football League.

Switching from Intravenous to Subcutaneous Biological Therapy for Inflammatory Bowel Disease Patients Remains a Challenge.

Biological inflammatory bowel disease (IBD) medications, once limited to intravenous (IV) administration, can now be administered both via IV and subcutaneously (SC). This study investigates patient preferences, willingness to switch from IV to SC, and associated factors. A questionnaire covering demographics, disease-related inquiries, quality of life, and IBD medication preferences was distributed via email, the Israeli Crohn's Disease and Ulcerative Colitis Foundation, infusion centers, and clinics. From 454 IBD patients (median age: 42 years; 55.7% female), responses revealed a preference for SC every 8 weeks, which is comparable to daily oral dosing. Both options were significantly favored over IV every 8 weeks and SC every 2 weeks, with no statistically significant differences between the latter two. However, among patients who were experienced with both SC and IV administration, a clear preference for SC administration every 2 weeks over IV every 8 weeks surfaced. Among IV-treated patients, 54.5% resisted switching to SC. Key reasons for this included medical staff presence (57.7%), a fear of needles (46.4%), belief in infusion efficacy (37.1%), and longer intervals between infusions (36.1%). Findings suggest that transitioning from IV to SC treatment is challenging due to patient resistance, which is influenced by specific factors. Identifying and addressing these obstacles is crucial for optimizing IBD management.

Evaluation of Acute Terminal Ileitis in Hospitalized Patients: Development of a Predictive Model to Distinguish Crohn's Disease from Other Etiologies.

Background/Objectives: Terminal ileitis (TI) is often identified on CT scans in emergency settings. Diagnosing Crohn's disease (CD) as a cause of TI is crucial due to its significant long-term implications. This study aimed to differentiate CD from other causes of acute TI and develop a predictive model for CD diagnosis. Methods: A retrospective case-control study was conducted at Shamir Medical Center including adults diagnosed with acute TI from January 2012 to December 2020. Patients with a history of inflammatory bowel disease or prior intestinal surgery were excluded. Patients were categorized into CD and non-CD groups based on their subsequent clinical course. A logistic regression model was developed and subsequently validated with additional patients hospitalized between 2021 and 2023. Results: Among 135 patients, 37 (27.4%) were diagnosed with CD. CD patients were younger (median age 27 vs. 39 years, p = 0.003), predominantly male (83.8% vs. 51%, p = 0.001), and had higher rates of chronic abdominal pain, diarrhea, anemia, and weight loss prior to hospitalization. Significant laboratory differences included higher platelet counts (p = 0.006) and lower mean corpuscular volume (MCV) (p = 0.001) in CD patients. Radiologic signs of complicated disease were more common in CD (35.1% vs. 4.1%, p < 0.001). The predictive model incorporating gender, abdominal pain history, and MCV showed an area under the curve (AUC) of 0.87, with a sensitivity of 100% and specificity of 63.6% in the validation group of 18 patients. Conclusions: This study identified key predictors of CD in patients presenting with acute TI and developed a predictive model with a substantial diagnostic capability. Use of this model for early identification and treatment of CD may potentially improve patient outcomes. Further prospective validation of this model is warranted.

Approach to esophageal absent contractility: can we do better?

Absent contractility (AC), a motility disorder characterized by the absence of esophageal contractions while maintaining normal lower esophageal sphincter relaxation, is recognized as a distinctive major disorder of peristalsis on esophageal high-resolution manometry that warrants comprehensive understanding. This unique motility disorder often co-occurs with connective tissue, rheumatologic or autoimmune diseases, with scleroderma being the classic example. Symptoms of gastroesophageal reflux are common. AC can profoundly impact patients' lives and result in a spectrum of complications, including erosive esophagitis, esophageal candidiasis, Barrett's esophagus, and malnutrition. To address the intricate complexities of AC and its multifaceted complications, a multidisciplinary approach is paramount. This approach considers the distinct clinical presentation and underlying rheumatologic conditions of the individual patient, recognizing the inherent diversity within this disorder. While medical management of gastroesophageal reflux remains the cornerstone of AC treatment, emerging surgical and endoscopic interventions offer additional therapeutic options for those grappling with this challenging condition. This comprehensive review provides an in-depth evaluation of recent advances in our understanding of AC and its management. It endeavors to offer valuable insights into therapeutic strategies for AC and its associated issues.

Epidemiology and risk factors for angiodysplasias of the upper and lower gastrointestinal tract: A large population-based study.

BACKGROUND: Gastrointestinal angiodysplasia (GIAD) is a rare diagnosis among the general population. We aimed to identify risk factors for GIADs and to determine the frequency rate in the general population. METHODS: A population-based retrospective study was performed including patients diagnosed with upper (stomach/duodenum) or lower (small bowel/colon) GIADs based on diagnostic codes from a large health maintenance organization. Control groups were matched for age and gender. Additional data including demographics, comorbidities, malignancies, and medications were collected. RESULTS: 991 upper GIADs and 3336 lower GIADs were included, compared to 7217 and 32,802 controls. The overall prevalence of GIAD was 0.092 %. 88 % of the upper and 85 % of the lower GIADs were diagnosed at ages ≥60, peaking at a prevalence of 0.37 % for ages 71-80. The most significant risk factors for GIADs included liver cirrhosis (OR 4.0 for lower GIAD and OR 7.0 for upper GIAD, p < 0.001), hypertension (OR 2.3 for lower GIAD and OR 2.8 for upper GIAD, p < 0.001) and aortic stenosis (OR 2.8 for lower GIAD and OR 2.0 for upper GIAD, p < 0.001). Other significant risk factors included ischemic heart disease, chronic renal failure, female gender, and chronic obstructive pulmonary disease. Interestingly, both upper and lower GIADs were found to be significantly less frequent in patients with malignancy. CONCLUSION: Identification of the clinical conditions and demographic factors associated with GIAD may improve our understanding of the etiology and the optimal treatment modalities for this rare condition.

Ethnic Differences in Anorectal Manometry Findings in Patients With Fecal Incontinence: Results From a Multiethnic Cohort According to the London Classification.

Background/Aims: Clinical rates of fecal incontinence (FI) are known to vary based on race and ethnicity. It is unclear if anorectal manometry (ARM) findings in patients with FI differ based on ethnicity. Methods: High-resolution ARM studies performed between 2014-2021 due to FI at 2 hospitals with multiethnic populations were retrospectively reviewed. Results: Four hundred and seventy-nine subjects were included--87 (18.2%) Arab Israelis, 76 (15.9%) immigrants from the former Soviet Union, and 316 (66.0%) Jewish Israelis. Median age was 67 years old (76.0% women: 90.4% were parous). The Arab Israeli group had higher rates of smoking, diabetes, and obesity. Over 95% of ARM's were abnormal per the London classification including 23% with "combined anal hypotension and hypocontractility," 36% with "anal normotension with anal hypocontractility," 67% with "dyssynergia," and 65% with either "rectal hyposensation" or "borderline rectal hyposensation." On univariate analyses, significant differences between the ethnic groups were noted in the rates of "anal hypotension with normal contractility," "combined anal hypotension with anal hypocontractility," and "dyssynergia." In multivariate logistic regression analyses controlling for age, gender, parity, smoking, diabetes, and obesity, the Arab Israeli group remained several times more likely to have "combined anal hypotension and hypocontractibility" compared to the other groups. Conclusions: Ethnicity impacts ARM findings in patients with FI. The reason for this is unclear and future studies on ethnically diverse populations evaluating the clinical relevance of these findings are warranted.

A Novel Model to Predict Inadequate Bowel Preparation Prior to Colonoscopy Incorporating Patients' Reactions to Drinking the Laxative.

BACKGROUND AND AIMS: Prior studies have identified predictors of inadequate preparation with limited success. We aimed to build a model that could predict the likelihood of inadequate preparation by also including factors related to the patient's reaction to drinking the laxative preparation. METHODS: Demographic, clinical, and preparation-related data were prospectively collected on patients undergoing colonoscopy. An inadequate preparation was defined as a Boston Bowel Preparation Scale < 6. Statistical analyses were performed to identify predictors of inadequate preparation and create a predictive model. RESULTS: 324 patients were included (age 67 +/- 14 years, 52% male). 77 (23.7%) had inadequate preparations. Diabetes (p < 0.001), cerebrovascular accident (CVA) (p < 0.001), incomplete prep consumption (p = 0.007), high school level education and above (p < 0.001), use of Bisacodyl (p = 0.005), >10 bowel movements (p = 0.02), and use of Sodium Picosulfate or low-volume polyethylene glycol (PEG) solution (2L) compared to PEG 3L (p < 0.001) were significant variables. In a multivariate analysis, prior CVA increased the risk for inadequate preparation (OR = 4.8, CI 1.6-14.5), whereas high school level education and above (OR = 0.4, CI 0.2-0.8), consumption of Bisacodyl (OR = 0.4, CI 0.2-0.8), >10 bowel movements (OR = 0.5, CI 0.3-0.9), and use of Sodium Picosulfate (OR = 0.5, CI 0.3-0.9) decreased the risk for inadequate prep. Using these, a predictive model for patients likely to have an inadequate colon preparation was created with an area under the curve of 0.74 (35% sensitivity, 90% specificity at a cutoff point of 39%). CONCLUSION: Given the low sensitivity, this predictive model does not appear ready for clinical use. However, due to its high specificity, it may be helpful in high-risk, sicker populations by preventing inadequately prepped procedures.