Indomethacin with or without prophylactic pancreatic stent placement to prevent pancreatitis after ERCP: a randomised non-inferiority trial.

BACKGROUND: The combination of rectally administered indomethacin and placement of a prophylactic pancreatic stent is recommended to prevent pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in high-risk patients. Preliminary evidence suggests that the use of indomethacin might eliminate or substantially reduce the need for stent placement, a technically complex, costly, and potentially harmful intervention. METHODS: In this randomised, non-inferiority trial conducted at 20 referral centres in the USA and Canada, patients (aged ≥18 years) at high risk for post-ERCP pancreatitis were randomly assigned (1:1) to receive rectal indomethacin alone or the combination of indomethacin plus a prophylactic pancreatic stent. Patients, treating clinicians, and outcomes assessors were masked to study group assignment. The primary outcome was post-ERCP pancreatitis. To declare non-inferiority, the upper bound of the two-sided 95% CI for the difference in post-ERCP pancreatitis (indomethacin alone minus indomethacin plus stent) would have to be less than 5% (non-inferiority margin) in both the intention-to-treat and per-protocol populations. This trial is registered with ClinicalTrials.gov (NCT02476279), and is complete. FINDINGS: Between Sept 17, 2015, and Jan 25, 2023, a total of 1950 patients were randomly assigned. Post-ERCP pancreatitis occurred in 145 (14·9%) of 975 patients in the indomethacin alone group and in 110 (11·3%) of 975 in the indomethacin plus stent group (risk difference 3·6%; 95% CI 0·6-6·6; p=0·18 for non-inferiority). A post-hoc intention-to-treat analysis of the risk difference between groups showed that indomethacin alone was inferior to the combination of indomethacin plus prophylactic stent (p=0·011). The relative benefit of stent placement was generally consistent across study subgroups but appeared more prominent among patients at highest risk for pancreatitis. Safety outcomes (serious adverse events, intensive care unit admission, and hospital length of stay) did not differ between groups. INTERPRETATION: For preventing post-ERCP pancreatitis in high-risk patients, a strategy of indomethacin alone was not as effective as a strategy of indomethacin plus prophylactic pancreatic stent placement. These results support prophylactic pancreatic stent placement in addition to rectal indomethacin administration in high-risk patients, in accordance with clinical practice guidelines. FUNDING: US National Institutes of Health.

The 2023 top 10 list of endoscopy topics in medical publishing: an annual review by the American Society for Gastrointestinal Endoscopy Editorial Board.

Using a systematic literature search of original articles published during 2023 in Gastrointestinal Endoscopy (GIE) and other high-impact medical and gastroenterology journals, the GIE Editorial Board of the American Society for Gastrointestinal Endoscopy compiled a list of the top 10 most significant topic areas in general and advanced GI endoscopy during the year. Each GIE Editorial Board member was directed to consider 3 criteria in generating candidate topics-significance, novelty, and impact on global clinical practice-and subject matter consensus was facilitated by the Chair through electronic voting and a meeting of the entire GIE Editorial Board. The 10 identified areas collectively represent advances in the following endoscopic spheres: GI bleeding, endohepatology, endoscopic palliation, artificial intelligence and polyp detection, artificial intelligence beyond the colon, better polypectomy and endoscopic mucosal resection, how to make endoscopy units greener, high quality upper endoscopy, endoscopic tissue apposition/closure devices, and endoscopic submucosal dissection. Each board member was assigned a topic area around which summarized relevant important articles, thereby generating this overview of the "top 10" endoscopic advances of 2023.

ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding.

We performed systematic reviews addressing predefined clinical questions to develop recommendations with the GRADE approach regarding management of patients with overt upper gastrointestinal bleeding. We suggest risk assessment in the emergency department to identify very-low-risk patients (e.g., Glasgow-Blatchford score = 0-1) who may be discharged with outpatient follow-up. For patients hospitalized with upper gastrointestinal bleeding, we suggest red blood cell transfusion at a threshold of 7 g/dL. Erythromycin infusion is suggested before endoscopy, and endoscopy is suggested within 24 hours after presentation. Endoscopic therapy is recommended for ulcers with active spurting or oozing and for nonbleeding visible vessels. Endoscopic therapy with bipolar electrocoagulation, heater probe, and absolute ethanol injection is recommended, and low- to very-low-quality evidence also supports clips, argon plasma coagulation, and soft monopolar electrocoagulation; hemostatic powder spray TC-325 is suggested for actively bleeding ulcers and over-the-scope clips for recurrent ulcer bleeding after previous successful hemostasis. After endoscopic hemostasis, high-dose proton pump inhibitor therapy is recommended continuously or intermittently for 3 days, followed by twice-daily oral proton pump inhibitor for the first 2 weeks of therapy after endoscopy. Repeat endoscopy is suggested for recurrent bleeding, and if endoscopic therapy fails, transcatheter embolization is suggested.

Automated Time-Released Reminders Improve Patient Access to Colonoscopy.

Unscheduled colonoscopy orders lead to missed opportunities for early diagnosis and screening. The aim of this study was to evaluate the effect of an automated time-released reminder program on conversion of colonoscopy orders to scheduled cases. In this prospective study, we compared patients ordered for a colonoscopy who were enrolled in an automated reminder program (intervention) with a historical cohort of patients ordered for a colonoscopy who did not receive scheduling reminders (control). The intervention group received automated text message and email reminders using a software platform at 1, 7, and 14 days after a colonoscopy order was placed. The percentage of colonoscopies scheduled within 14 days of order placement improved from 66.0% in the control group to 73.4% in the intervention group (p = .001). The percentage of colonoscopies scheduled within 30 days improved from 73.6% to 90.0% (p < .0001). For colonoscopies ordered by a nongastroenterologist, the percentage of cases scheduled within 30 days of order placement improved from 65.8% in the control group to 90.0% in the intervention group (p < .0001). There was a 10% decrease in phone calls with endoscopy staff for the intervention group relative to the control group. Automated reminders for colonoscopy scheduling improve efficiency in colonoscopy scheduling.

Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group.

Description: This update of the 2010 International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding (UGIB) refines previous important statements and presents new clinically relevant recommendations. Methods: An international multidisciplinary group of experts developed the recommendations. Data sources included evidence summarized in previous recommendations, as well as systematic reviews and trials identified from a series of literature searches of several electronic bibliographic databases from inception to April 2018. Using an iterative process, group members formulated key questions. Two methodologists prepared evidence profiles and assessed quality (certainty) of evidence relevant to the key questions according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Group members reviewed the evidence profiles and, using a consensus process, voted on recommendations and determined the strength of recommendations as strong or conditional. Recommendations: Preendoscopic management: The group suggests using a Glasgow Blatchford score of 1 or less to identify patients at very low risk for rebleeding, who may not require hospitalization. In patients without cardiovascular disease, the suggested hemoglobin threshold for blood transfusion is less than 80 g/L, with a higher threshold for those with cardiovascular disease. Endoscopic management: The group suggests that patients with acute UGIB undergo endoscopy within 24 hours of presentation. Thermocoagulation and sclerosant injection are recommended, and clips are suggested, for endoscopic therapy in patients with high-risk stigmata. Use of TC-325 (hemostatic powder) was suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers. Pharmacologic management: The group recommends that patients with bleeding ulcers with high-risk stigmata who have had successful endoscopic therapy receive high-dose proton-pump inhibitor (PPI) therapy (intravenous loading dose followed by continuous infusion) for 3 days. For these high-risk patients, continued oral PPI therapy is suggested twice daily through 14 days, then once daily for a total duration that depends on the nature of the bleeding lesion. Secondary prophylaxis: The group suggests PPI therapy for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis.

Thirty-Day Readmission Among Patients With Non-Variceal Upper Gastrointestinal Hemorrhage and Effects on Outcomes.

BACKGROUND & AIMS: We aimed to determine the rate of hospital readmission within 30 days of non-variceal upper gastrointestinal hemorrhage and its impact on mortality, morbidity, and health care use in the United States. METHODS: We performed a retrospective study using the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project Nationwide Readmission Database for the year 2014 (data on 14.9 million hospital stays at 2048 hospitals in 22 states). We collected data on hospital readmissions of 203,220 adults who were hospitalized for urgent non-variceal upper gastrointestinal hemorrhage and discharged. The primary outcome was rate of all-cause readmission within 30 days of discharge. Secondary outcomes were reasons for readmission, readmission mortality rate, morbidity (shock and prolonged mechanical ventilation) and resource use (length of stay and total hospitalization costs and charges). Independent risk factors for readmission were identified using Cox regression analysis. RESULTS: The 30-day rate of readmission was 13%. Only 18% of readmissions were due to recurrent non-variceal upper gastrointestinal bleeding. The rate of death among patients readmitted to the hospital (4.7%) was higher than that for index admissions (1.9%) (P < .01). A higher proportion of readmitted patients had morbidities requiring prolonged mechanical ventilation (1.5%) compared with index admissions (0.8%) (P < .01). A total of 133,368 hospital days was associated with readmission, and the total health care in-hospital economic burden was $30.3 million (in costs) and $108 million (in charges). Independent predictors of readmission were Medicaid insurance, higher Charlson comorbidity score, lower income, residence in a metropolitan area, hemorrhagic shock, and longer stays in the hospital. Older age, private or no insurance, upper endoscopy, and prolonged mechanical ventilation were associated with lower odds for readmission. CONCLUSIONS: In a retrospective study of patients hospitalized for non-variceal upper gastrointestinal hemorrhage, 13% are readmitted to the hospital within 30 days of discharge. Readmission is associated with higher mortality, morbidity, and resource use. Most readmissions are not for recurrent gastrointestinal bleeding.

Clinicopathologic and genetic characteristics of interval colorectal carcinomas favor origin from missed or incompletely excised precursors.

Interval colorectal cancers may arise from missed or incompletely excised precursors or from a unique rapid progression pathway. We compared the clinicopathologic and molecular profiles of interval and matched non-interval colorectal cancer to determine whether interval colorectal cancers harbor any unique genetic characteristics. Fifty one of 982 colorectal cancer (5.2%) were categorized as interval colorectal cancer, defined as colorectal cancer detected in a diagnostic examination prior to the next recommended colonoscopy and at least 1 year after the last colonoscopy. Clinicopathologic characteristics of interval colorectal cancer were compared to non-interval colorectal cancer matched 1:1 on age, gender, and tumor location. Molecular profile of a subset of interval colorectal cancer (n = 20) and matched (1:2) non-interval colorectal cancer (n = 40) were evaluated using next generation sequencing. Interval colorectal cancer were more likely to occur in the right colon (55% vs. 35%; p = 0.02) and in patients > 70 years of age (55% vs. 34%; p = 0.002). Clinicopathologic features and aberrant DNA mismatch repair protein expression were not significantly different between interval and matched non-interval colorectal cancer. The frequency and spectrum of genetic alterations was also similar in interval and matched non-interval colorectal cancer. Similar findings were seen when analysis was restricted to interval colorectal cancer diagnosed <5 years after last colonoscopy (n = 42). Interval and non-interval colorectal cancers share similar clinicopathologic and genetic profiles when matched for tumor location. Interval colorectal cancers and are more likely to develop from missed or incompletely excised precursors rather than a unique rapid progression pathway.

Impact of Insurance Status and Race on Outcomes in Nonvariceal Upper Gastrointestinal Hemorrhage: A Nationwide Analysis.

BACKGROUND AND GOALS: We examined the interaction between race, insurance, and important outcomes in nonvariceal upper gastrointestinal hemorrhage (NVUGIH). STUDY: Adults with NVUGIH were selected from the National Inpatient Sample. PRIMARY OUTCOME: in-hospital mortality. SECONDARY OUTCOMES: treatment modalities [esophagogastroduodenoscopy (EGD), early EGD, and endoscopic or radiologic therapy], and resource utilization (length of hospital stay and total hospitalization charges). RESULTS: Mortality was similar for Medicare and private insurance [adjusted odds ratios (aOR): 1.15 95% confidence interval (CI) 0.90 to 1.47), P=0.24], but higher for under/uninsured patients [aOR: 1.84 (CI: 1.42 to 2.40), P<0.01]. Compared with Medicare, patients with private insurance had more EGDs [aOR: 1.35 (CI: 1.23 to 1.48), P<0.01], early EGDs [aOR: 1.29 (CI: 1.21 to 1.38), P<0.01], and endoscopic [aOR: 1.19 (CI: 1.11 to 1.27), P<0.01], or radiologic therapy [aOR:1.35 (CI: 1.06 to 1.71), P=0.01]. Patients who were under/uninsured had less EGDs [aOR: 0.84 (CI: 0.76 to 0.91), P<0.01] or endoscopic therapy [aOR: 0.74 (CI: 0.68 to 0.81), P<0.01], but similar odds of early EGD [aOR: 0.95 (CI: 0.88 to 1.02), P=0.13] or radiologic therapy [aOR: 1.01 (CI: 0.75 to 1.37), P=0.75]. Compared with whites, blacks had lower [aOR: 0.73 (CI: 0.58 to 0.93), P=0.01] and Native Americans higher mortality [aOR: 2.60 (CI: 1.57 to 4.13), P<0.01]. Blacks were less likely [aOR: 0.86 (CI: 0.79 to 0.94), P<0.01] and Asians more likely [aOR: 1.24 (CI: 1.05 to 1.47), P=0.01] to have EGDs. Both blacks and Hispanics had lower, whereas Asians had higher early EGD rates. Patients with private insurance had lower total charges [adjusted mean difference: -$2761 (CI: -$4617 to -$906), P<0.01]. CONCLUSIONS: Insurance and race have independent effects on NVUGIH mortality, therapeutic modalities used, and resource utilization. Black and under/uninsured patients have the worst outcomes.

The Impact of Obesity on Mortality and Other Outcomes in Patients With Nonvariceal Upper Gastrointestinal Hemorrhage in the United States.

GOALS: To quantify in patients with nonvariceal upper gastrointestinal hemorrhage (NVUGIH) the relationship between obesity and mortality, disease severity, treatment modalities, and resource utilization. BACKGROUND: NVUGIH is the most common gastrointestinal emergency. STUDY: Adults with a principal diagnosis of NVUGIH were selected from the 2014 National Inpatient Sample. The primary outcome was in-hospital mortality. Secondary outcomes were hemorrhagic shock, prolonged mechanical ventilation (PMV), upper endoscopy [esophagogastroduodenoscopy (EGD)], radiologic treatment, surgery, length of hospital stay (LOS), and total hospitalization costs and charges. Confounders were adjusted for using multivariable regression analyses. RESULTS: In total, 227,480 admissions with NVUGIH were included, 11.70% of whom were obese. Obese and nonobese patients had similar odds of mortality (aOR: 0.88; 95% confidence interval [CI]: 0.69-1.12; P=0.30), EGD within 24 hours of admission (aOR: 0.95; CI: 0.89-1.01; P=0.10), radiologic treatment (aOR: 1.06; CI: 0.82-1.35; P=0.66), and surgery (aOR: 1.27; CI: 0.94-1.70; P=0.11). However, obese patients had higher odds of shock (aOR: 1.30; CI: 1.14-1.49; P<0.01), PMV (aOR: 1.39; CI: 1.18-1.62; P<0.01), undergoing an EGD (aOR: 1.27; CI: 1.16-1.40; P<0.01), needing endoscopic therapy (aOR: 1.18; CI: 1.09-1.27; P<0.01), a longer LOS (0.31 d; CI: 0.16-0.46 d; P<0.01), higher costs ($1075; CI: $636-$1514; P<0.01), and higher charges ($4084; CI: $2060-$6110; P<0.01) compared with nonobese patients. CONCLUSIONS: Obesity is not an independent predictor of NVUGIH mortality. However, obesity is associated with a more severe disease course (shock and PMV), higher rates of EGD and endoscopic therapy use, and significant increases in resource utilization (hospital LOS, total hospitalization costs, and charges).

Impact of Automated Time-released Reminders on Patient Preparedness for Colonoscopy.

GOALS: To evaluate the effect of an automated time-released colonoscopy reminder program on preparation quality and the rates of canceled procedures. BACKGROUND: Patients missing colonoscopy appointments or arriving with inadequate bowel preparations result in delays in care and increase in health care costs. STUDY: We initiated a quality improvement program which included switching to a split-dose preparation and delivering preparation instructions and appointment reminders via text messages and emails sent with an automated time-released HIPAA-compliant software platform. All patients scheduled for a colonoscopy from March through June 2017 were enrolled unless mobile phone, email, or preparation type data was missing (nonintervention cohort). Primary outcome metrics were the rate of adequate bowel preparation and the rate of canceled procedures. Outcomes of the intervention group were compared with outcomes from colonoscopies performed from March through June 2016 (baseline cohort). RESULTS: There were 1497 patients (40.7% male, mean age 56.4 y) enrolled in the automated reminder program. Compared with the baseline cohort, the rate of adequate bowel preparation increased from 88.5% to 96.2% (P<0.0001). The rate of canceled procedures decreased from 6.1% to 4.3% (P=0.02). On multivariable analysis, the automated reminder program improved adequate preparation quality 2.85-fold (95% confidence interval, 2.03-3.99; P<0.0001). Sensitivity analysis comparing the intervention to nonintervention cohorts showed that improvement in preparation quality was attributable to the automated reminder program. CONCLUSIONS: Implementation of automated time-released colonoscopy preparation reminders via text messages and emails improved patient preparedness for colonoscopy, with significantly improved bowel preparation quality and fewer canceled procedures.

The SAFE-T assessment tool: derivation and validation of a web-based application for point-of-care evaluation of gastroenterology fellow performance in colonoscopy.

BACKGROUND AND AIMS: Attending assessment is a critical part of endoscopic education for gastroenterology fellows. The aim of this study was to develop and validate a concise assessment tool to evaluate real-time fellow performance in colonoscopy administered via a web-based application. METHODS: The Skill Assessment in Fellow Endoscopy Training (SAFE-T) tool was derived as a novel 5-question evaluation tool that captures both summative and formative feedback adapted into a web-based application. A prospective study of 15 gastroenterology fellows (5 fellows each from years 1 to 3 of training) was performed using the SAFE-T tool. An independent reviewer evaluated a subset of these procedures and completed the SAFE-T tool and Mayo Colonoscopy Skills Assessment Tool (MCSAT) for reliability testing. RESULTS: Twenty-six faculty completed 350 SAFE-T evaluations of the 15 fellows in the study. The mean SAFE-T overall score (year 1, 2.00; year 2, 3.84; year 3, 4.28) differentiated each sequential fellow year of training (P < .0001). The mean SAFE-T overall score decreased with increasing case complexity score, with straightforward cases compared with average cases (4.07 vs 3.50, P < .0001), and average cases compared with challenging cases (3.50 vs 3.08, P = .0134). In dual-observed procedures, the SAFE-T tool showed excellent inter-rater reliability with a kappa agreement statistic of 0.898 (P < .0001). Correlation of the SAFE-T overall score with the MCSAT overall hands-on and individual motor scores was excellent (each r > 0.90, P < .0001). CONCLUSIONS: We developed and validated the SAFE-T assessment tool, a concise and web-based means of assessing real-time gastroenterology fellow performance in colonoscopy.

Development and validation of the SIMPLE endoscopic classification of diminutive and small colorectal polyps.

BACKGROUND: Prediction of histology of small polyps facilitates colonoscopic treatment. The aims of this study were: 1) to develop a simplified polyp classification, 2) to evaluate its performance in predicting polyp histology, and 3) to evaluate the reproducibility of the classification by trainees using multiplatform endoscopic systems. METHODS: In phase 1, a new simplified endoscopic classification for polyps - Simplified Identification Method for Polyp Labeling during Endoscopy (SIMPLE) - was created, using the new I-SCAN OE system (Pentax, Tokyo, Japan), by eight international experts. In phase 2, the accuracy, level of confidence, and interobserver agreement to predict polyp histology before and after training, and univariable/multivariable analysis of the endoscopic features, were performed. In phase 3, the reproducibility of SIMPLE by trainees using different endoscopy platforms was evaluated. RESULTS: Using the SIMPLE classification, the accuracy of experts in predicting polyps was 83 % (95 % confidence interval [CI] 77 % - 88 %) before and 94 % (95 %CI 89 % - 97 %) after training (P â€Š= 0.002). The sensitivity, specificity, positive predictive value, and negative predictive value after training were 97 %, 88 %, 95 %, and 91 %. The interobserver agreement of polyp diagnosis improved from 0.46 (95 %CI 0.30 - 0.64) before to 0.66 (95 %CI 0.48 - 0.82) after training. The trainees demonstrated that the SIMPLE classification is applicable across endoscopy platforms, with similar post-training accuracies for narrow-band imaging NBI classification (0.69; 95 %CI 0.64 - 0.73) and SIMPLE (0.71; 95 %CI 0.67 - 0.75). CONCLUSIONS: Using the I-SCAN OE system, the new SIMPLE classification demonstrated a high degree of accuracy for adenoma diagnosis, meeting the ASGE PIVI recommendations. We demonstrated that SIMPLE may be used with either I-SCAN OE or NBI.

Natural Language Processing Accurately Calculates Adenoma and Sessile Serrated Polyp Detection Rates.

BACKGROUND: ADR is a widely used colonoscopy quality indicator. Calculation of ADR is labor-intensive and cumbersome using current electronic medical databases. Natural language processing (NLP) is a method used to extract meaning from unstructured or free text data. AIMS: (1) To develop and validate an accurate automated process for calculation of adenoma detection rate (ADR) and serrated polyp detection rate (SDR) on data stored in widely used electronic health record systems, specifically Epic electronic health record system, Provation® endoscopy reporting system, and Sunquest PowerPath pathology reporting system. METHODS: Screening colonoscopies performed between June 2010 and August 2015 were identified using the Provation® reporting tool. An NLP pipeline was developed to identify adenomas and sessile serrated polyps (SSPs) on pathology reports corresponding to these colonoscopy reports. The pipeline was validated using a manual search. Precision, recall, and effectiveness of the natural language processing pipeline were calculated. ADR and SDR were then calculated. RESULTS: We identified 8032 screening colonoscopies that were linked to 3821 pathology reports (47.6%). The NLP pipeline had an accuracy of 100% for adenomas and 100% for SSPs. Mean total ADR was 29.3% (range 14.7-53.3%); mean male ADR was 35.7% (range 19.7-62.9%); and mean female ADR was 24.9% (range 9.1-51.0%). Mean total SDR was 4.0% (0-9.6%). CONCLUSIONS: We developed and validated an NLP pipeline that accurately and automatically calculates ADRs and SDRs using data stored in Epic, Provation® and Sunquest PowerPath. This NLP pipeline can be used to evaluate colonoscopy quality parameters at both individual and practice levels.

Association between an increase in blood urea nitrogen at 24 hours and worse outcomes in acute nonvariceal upper GI bleeding.

BACKGROUND AND AIMS: An increase in blood urea nitrogen (BUN) at 24 hours is a solitary and significant predictor of mortality in patients with acute pancreatitis, which may predict worse outcomes in the similarly resuscitation-requiring condition of acute nonvariceal upper GI bleeding (UGIB). The aim of our study was to assess whether an increase in BUN at 24 hours is predictive of worse clinical outcomes in acute nonvariceal UGIB. METHODS: A retrospective cohort study including patients admitted to an academic hospital from 2004 to 2014 was conducted. An increase in BUN was defined as an increase in BUN at 24 hours of hospitalization compared with BUN at presentation. The primary outcome was a composite of inpatient death, inpatient rebleeding, need for surgical or radiologic intervention, or endoscopic reintervention. Associations between BUN change and outcomes were assessed via the Pearson χ2 test and the Fisher exact test and via logistic regression for adjusted analyses. RESULTS: There were 357 patients included in the analysis with a mean age of 64 years; 54% were men. The mean change in BUN was -10.1 mg/dL (standard deviation, 12.7 mg/dL). Patients with an increased BUN (n = 37 [10%]) were significantly more likely to experience the composite outcome (22% vs 9%, P = .014), including an increased risk of inpatient death (8% vs 1%, P = .004), compared with patients with a decreased or unchanged BUN (n = 320 [90%]). In a logistic regression model adjusting for the AIMS65 score, an increase in BUN was independently associated with an increased risk for the composite outcome (odds ratio, 2.75; P = .026). CONCLUSION: Increasing BUN at 24 hours likely reflects under resuscitation and is a predictor of worse outcomes in patients with acute nonvariceal UGIB.

Timing of upper endoscopy influences outcomes in patients with acute nonvariceal upper GI bleeding.

BACKGROUND AND AIMS: Current guidelines advise that upper endoscopy be performed within 24 hours of presentation in patients with acute nonvariceal upper GI bleeding (UGIB). However, the role of urgent endoscopy (<12 hours) is controversial. Our aim was to assess whether patients admitted with acute nonvariceal UGIB with lower-risk versus high-risk bleeding have different outcomes with urgent compared with nonurgent endoscopy. METHODS: A retrospective cohort study was conducted of patients admitted to an academic hospital with nonvariceal UGIB. The primary outcome was a composite of inpatient death from any cause, inpatient rebleeding, need for surgical or interventional radiologic intervention, or endoscopic reintervention. The Glasgow-Blatchford score (GBS) was calculated; lower risk was defined as a GBS < 12, and high risk was defined as a GBS ≥ 12. RESULTS: Of 361 patients, 37 patients (10%) experienced the primary outcome. Patients who underwent urgent endoscopy had a greater than 5-fold increased risk of reaching the composite outcome (unadjusted odds ratio [OR], 5.6; 95% confidence interval [CI], 2.8-11.4; P < .001). Lower-risk patients who were taken urgently to endoscopy were more likely to reach the composite outcome (adjusted OR, 0.71 per 6 hours; 95% CI, 0.55-0.91; P = .008). However, in the high-risk patients, time to endoscopy was not a significant predictor of the primary outcome (adjusted OR, 0.93 per 6 hours; 95% CI, 0.77-1.13; P = .47; adjusted P for interaction = .039). CONCLUSION: Urgent endoscopy is a predictor of worse outcomes in select patients with acute nonvariceal UGIB.

Impact of physician compliance with colonoscopy surveillance guidelines on interval colorectal cancer.

BACKGROUND AND AIMS: Interval colorectal cancer (iCRC) incidence is the criterion standard benchmark for measuring the effectiveness of colonoscopy. Colonoscopy surveillance guidelines are designed to minimize iCRC cases. Our aims were to describe characteristics of iCRC patients and to assess whether development of iCRC is related to colonoscopy surveillance guideline intervals. METHODS: We performed a retrospective cohort study of postcolonoscopy iCRC cases in a large healthcare system. Guideline-based colonoscopy intervals were calculated based on the 2012 U.S. Multi-Society Task Force for Colorectal Cancer colonoscopy surveillance guidelines. Backward stepwise linear regression was used to determine predictors of iCRC before guideline-recommended follow-up intervals. RESULTS: We identified 245 iCRC cases (mean age, 69.4 years; 56.3% male) out of 5345 colon cancers evaluated for a prevalence of 4.60%. On index colonoscopy, 75.1% had an adequate preparation, 93.0% reached the cecum, and 52.5% had polyps. iCRC developed before the guideline-recommended interval in 59.1% of patients (94/159). Independent predictive factors of this finding were inadequate preparation (OR, .012; 95% CI, .003-.06; P < .0001) and ≥3 polyps on index colonoscopy (OR, .2; 95% CI, .078-.52; P = .0009). An endoscopist-recommended follow-up interval past the guideline-recommended interval was seen in 23.9% of cases (38/159). Most (34/38, 89.5%) of these iCRCs had inadequate preparation and were diagnosed after the guideline-based follow-up interval. CONCLUSIONS: Current colonoscopy surveillance guidelines may be inadequate to prevent many iCRC cases. Physician noncompliance with guideline-based surveillance intervals may increase in iCRC cases, especially in patients with an initially inadequate bowel preparation.

Endoscopic Localization of Colon Cancer Is Frequently Inaccurate.

BACKGROUND: Colonoscopic location of a tumor can influence both the surgical procedure choice and overall treatment strategy. AIMS: To determine the accuracy of colonoscopy in determining the location of colon cancer compared to surgical localization and to elucidate factors that predict discordant colon cancer localization. METHODS: We conducted a retrospective cross-sectional study of colon cancers diagnosed on colonoscopy at two academic tertiary-care hospitals and two affiliated community hospitals from 2012 to 2014. Colon cancer location was obtained from the endoscopic and surgical pathology reports and characterized by colon segment. We collected data on patient demographics, tumor characteristics, endoscopic procedure characteristics, surgery planned, and surgery performed. Univariate analyses using Chi-squared test and multivariate analysis using forward stepwise logistic regression were performed to determine factors that predict discordant colon cancer localization. RESULTS: There were 110 colon cancer cases identified during the study period. Inaccurate endoscopic colon cancer localization was found in 29% (32/110) of cases. These included 14 cases (12.7%) that were discordant by more than one colonic segment and three cases where the presurgical planned procedure was significantly changed at the time of surgery. On univariate analyses, right-sided colon lesions were associated with increased inaccuracy (43.8 vs 24.4%, p = 0.04). On multivariate analysis, right-sided colon lesions remained independently associated with inaccuracy (OR 1.74, 95% CI 1.03-2.93, p = 0.04). CONCLUSIONS: Colon cancer location as determined by colonoscopy is often inaccurate, which can result in intraoperative changes to surgical management, particularly in the right colon.

A Prospective, Multicenter Study of the AIMS65 Score Compared With the Glasgow-Blatchford Score in Predicting Upper Gastrointestinal Hemorrhage Outcomes.

BACKGROUND: The AIMS65 score and the Glasgow-Blatchford risk score (GBRS) are validated preendoscopic risk scores for upper gastrointestinal hemorrhage (UGIH). GOALS: To compare the 2 scores' performance in predicting important outcomes in UGIH. STUDY: A prospective cohort study in 2 tertiary referral centers and 1 community teaching hospital. Adults with UGIH were included. The AIMS65 score and GBRS were calculated for each patient. The primary outcome was inpatient mortality. Secondary outcomes were 30-day mortality, in-hospital rebleeding, 30-day rebleeding, length of stay, and a composite endpoint of in-hospital mortality, transfusions, or need for intervention (endoscopic, radiologic, or surgical treatment). The area under the receiver operating characteristic curve (AUROC) was calculated for each score and outcome. RESULTS: A total of 298 patients were enrolled. The AIMS65 score was superior to the GBRS in predicting in-hospital mortality (AUROC, 0.85 vs. 0.66; P<0.01) and length of stay (Somer's D, 0.21 vs. 0.13; P=0.04). The scores were similar in predicting 30-day mortality (AUROC, 0.74 vs. 0.65; P=0.16), in-hospital rebleeding (AUROC, 0.69 vs. 0.62; P=0.19), 30-day rebleeding (AUROC, 0.63 vs. 0.63; P=0.90), and the composite outcome (AUROC, 0.57 vs. 0.59; P=0.49). The optimal cutoffs for predicting in-hospital mortality were an AIMS65 score of 3 and a GBRS score of 10. For predicting rebleeding, the optimal cutoffs were 2 and 10, respectively. CONCLUSIONS: The AIMS65 score is superior to the GBRS for predicting in-hospital mortality and hospital length of stay for patients with UGIH. The AIMS65 score and GBRS are similar in predicting 30-day mortality, rebleeding, and a composite endpoint.