Gastric Emptying Scans: Poor Adherence to National Guidelines.

BACKGROUND: Accurately diagnosing gastroparesis relies upon gastric emptying scintigraphy (GES) being performed correctly. Jointly published protocol guidelines have long been available; however, the extent to which practitioners adhere to these guidelines is unknown. AIMS: This study aimed to assess national compliance with established GES protocol guidelines. METHODS: We developed a questionnaire addressing the key protocol measures outlined in the Consensus Recommendations for Gastric Emptying Scintigraphy. Survey questions addressed patient information collection (15), patient preparation and procedure protocol (16), meal content and preparation (7), imaging (3), interpretation (4), reporting (7), and institutional demographic data (7). The anonymous questionnaire was distributed electronically to members of the Society of Nuclear Medicine and Medical Imaging (SNMMI) and non-member recipients of the SNMMI daily email newsletter. One response per medical institution was permitted. RESULTS: A total of 121 out of 872 potential medical institutions (MI) responded (13.9%); 49 (40.4%) were academic/teaching medical centers. The annual number (mean) of GES procedures was 199.9 (range 5-2000 GES/year). On average, MI performed 33.5/52 (64%) of protocol measures according to guidelines while academic medical centers performed 31.5/52 (61%) of protocol measures according to guidelines. Only 4 out of 88 MI (4.5%) performed GES while adhering to three critical measures: validated study duration; controlled blood glucose levels; and proper restriction of medications. CONCLUSIONS: Low compliance with GES protocol guidelines, even among academic medical centers, raises the likely possibility of misdiagnosis and improper management of upper gastrointestinal symptoms. These results highlight a need for increased awareness of protocol guidelines for gastric scintigraphy.

Nonneoplastic polypectomy during screening colonoscopy: the impact on polyp detection rate, adenoma detection rate, and overall cost.

BACKGROUND: The frequency of nonneoplastic polypectomy (NNP) and its impact on the polyp detection rate (PDR) is unknown. The correlation between NNP and adenoma detection rate (ADR) and its impact on the cost of colonoscopy has not been investigated. OBJECTIVE: To determine the rate of NNP in screening colonoscopy, the impact of NNP on the PDR, and the correlation of NNP with ADR. The increased cost of NNP during screening colonoscopy also was calculated. DESIGN: We reviewed all screening colonoscopies. PDR and ADR were calculated. We then calculated a nonneoplastic polyp detection rate (patients with ≥1 nonneoplastic polyp). SETTING: Tertiary-care referral center. PATIENTS: Patients who underwent screening colonoscopies from 2010 to 2011. INTERVENTIONS: Colonoscopy. MAIN OUTCOME MEASUREMENTS: ADR, PDR, NNP rate. RESULTS: A total of 1797 colonoscopies were reviewed. Mean (±standard deviation) PDR was 47.7%±12.0%, and mean ADR was 27.3%±6.9%. The overall NNP rate was 10.4%±7.1%, with a range of 2.4% to 28.4%. Among all polypectomies (n=2061), 276 were for nonneoplastic polyps (13.4%). Endoscopists with a higher rate of nonneoplastic polyp detection were more likely to detect an adenoma (odds ratio 1.58; 95% confidence interval, 1.1-1.2). With one outlier excluded, there was a strong correlation between ADR and NNP (r=0.825; P<.001). The increased cost of removal of nonneoplastic polyps was $32,963. LIMITATIONS: Retrospective study. CONCLUSION: There is a strong correlation between adenoma detection and nonneoplastic polyp detection. The etiology is unclear, but nonneoplastic polyp detection rate may inflate the PDR for some endoscopists. NNP also adds an increased cost. Increasing the awareness of endoscopic appearances through advanced imaging techniques of normal versus neoplastic tissue may be an area to improve cost containment in screening colonoscopy.

Multi-Dimensional Gastrointestinal Symptom Severity Index: Validation of a Brief GI Symptom Assessment Tool.

UNLABELLED: Few instruments have been developed and validated for the evaluation of multi-dimensional GI symptoms. The Gastrointestinal Symptoms Severity Index (GISSI), a multi-dimensional, self-report instrument, was designed as a brief measure of the frequency, severity, and bothersomeness of individual GI and pelvic floor/urogynecologic symptoms. AIM: To report the psychometric properties of the GISSI subscales, including factorial structure, validity, and internal consistency. METHODS: The GISSI included 32 items that assessed upper and lower GI symptoms and seven items related to pelvic floor/urogynecologic symptoms. A total of 934 patients presenting for upper and lower GI complaints completed the questionnaire between January 2013 and December 2013. The sample was randomly split into derivation (n = 466) and validation datasets (n = 468). A non-patient sample of 200 was collected separately. RESULTS: Exploratory factor analysis supported a six-factor model for the derivation sample that accounted for 69.3 % of the total variance. The six GI symptom clusters were labeled as constipation/difficult defecation (five items), abdominal pain/discomfort (four items), dyspepsia (four items), diarrhea/anal incontinence (four items), GERD/chest symptoms (four items), and nausea/vomiting (two items). Inclusion of additional items related to female pelvic floor/urogynecologic symptoms resulted in a separate factor. Confirmatory factor analysis of the validation dataset supported the a priori hypothesized six-factor measurement model (Χ (2)(428) = 1462.98; P < 0.001; GFI = .88; RMSEA = .051). CONCLUSION: The GISSI demonstrated good to excellent psychometric properties and provided multi-dimensional scaling of prominent GI symptom clusters. Further validation may provide an efficient, valid, and reliable measure of patient-reported clinical outcomes.

Measurement of polypectomy rate by using administrative claims data with validation against the adenoma detection rate.

BACKGROUND: The adenoma detection rate (ADR) is a main quality indicator in colonoscopy but has many challenges for calculating. The polypectomy rate (PR) may be calculable from administrative claims data, but this has not been validated against the ADR. OBJECTIVE: To determine whether a PR calculated from United States billing claims data is an accurate surrogate for the ADR. DESIGN: A PR was calculated by using billing claims data from Current Procedural Terminology codes. The ADR was calculated for each endoscopist by using an endoscopy report database to which the pathology report data had been added. The relationship between PR and ADR was evaluated with the Pearson correlation coefficient. The ADR was plotted against the PR by individual endoscopist, and a least-squares regression line was created. A t test was used to analyze the differences in lesion detection between endoscopists with a PR above and below the benchmark PR. SETTING: Tertiary-care, outpatient endoscopy center. PATIENTS: All ages undergoing colonoscopy. MAIN OUTCOME MEASUREMENTS: PR and ADR. RESULTS: A total of 5382 colonoscopies were reviewed. A significant relationship between endoscopists' calculated PRs and ADRs was seen (r = 0.85; P < .001). Endoscopists needed a PR of 35% to achieve the recommended benchmark ADR of 20%. Endoscopists with PRs of 35% or greater had an ADR of 27% (6.2 standard deviation [SD]) as compared with 19% (1.9 SD) for those with PRs less than 35% (P = .0029). LIMITATIONS: Study population. CONCLUSION: Calculated PR from billing claims data is an accurate surrogate for ADR and may become an important quality measure for external and internal use.

IBS patients' willingness to take risks with medications.

OBJECTIVES: We explored irritable bowel syndrome (IBS) patients' impulsivity and risk-taking behavior and their willingness to take medication risks. METHODS: A validated questionnaire assessed the illness experience of IBS patients. A standard gamble evaluated respondents' willingness to take medication risks. RESULTS: IBS patients with severe symptoms were more willing to take significant medication risks than those with mild or moderate symptoms. Impulsivity scores were not associated with an increased likelihood of taking medication risks. Age, gender, and years of IBS symptoms were not associated with medication risk-taking behavior. IBS patients reported they would accept a median 1% risk of sudden death for a 99% chance of cure for their symptoms using a hypothetical medication. CONCLUSIONS: IBS patients are willing to take significant medication risks to cure their symptoms. To counsel patients effectively, physicians must determine and understand IBS patients' risk aversion.

Self dilation as a treatment for resistant benign esophageal strictures: outcome, technique, and quality of life assessment.

BACKGROUND: Resistant benign esophageal strictures can have a negative impact on patients' quality of life. A portion of these patients require frequent physician performed dilations, leading to numerous interactions with their attendant inconvenience and sense of dependence. This study demonstrates the efficacy, safety and effect on quality of life of this under-utilized technique. METHODS: A retrospective chart review was performed for all patients undergoing esophageal self dilation at our institution between January 2003 and November 2009. The impact on quality of life was evaluated using a telephone questionnaire specifically designed to explore emotional, social and financial impacts. RESULTS: Of the 11 patients who initially began self dilation for non-malignant strictures, nine are included in this study. Median follow-up was 35.4 months (range 6-168). No significant complications were reported. When asked to compare self dilation with physician performed dilation a large proportion of patients reported financial benefits, and a majority reported being more socially active. Overall quality of life improvement was reported by almost all of the participants in the study. Global scores for dysphagia and overall quality of life were significantly improved under conditions of self dilation versus physician performed dilation (P = 0.008 and P = 0.016, respectively). CONCLUSIONS: Our results suggest that esophageal self dilation can be a safe and effective treatment modality in motivated patients with benign resistant esophageal strictures. Esophageal self dilation has a positive impact on emotional, social, and financial aspects of patient's life. Self dilation should be considered a treatment option in all patients with benign resistant esophageal strictures.

Increased colonic pain sensitivity in irritable bowel syndrome is the result of an increased tendency to report pain rather than increased neurosensory sensitivity.

OBJECTIVE: The aim was to determine whether lower visceral pain thresholds in irritable bowel syndrome (IBS) primarily reflect physiological or psychological factors. METHODS: Firstly, 121 IBS patients and 28 controls underwent balloon distensions in the descending colon using the ascending methods of limits (AML) to assess pain and urge thresholds. Secondly, sensory decision theory analysis was used to separate physiological from psychological components of perception: neurosensory sensitivity (p(A)) was measured by the ability to discriminate between 30 mm Hg vs 34 mm Hg distensions; psychological influences were measured by the report criterion-that is, the overall tendency to report pain, indexed by the median intensity rating for all distensions, independent of intensity. Psychological symptoms were assessed using the Brief Symptom Inventory (BSI). RESULTS: IBS patients had lower AML pain thresholds (median: 28 mm Hg vs 40 mm Hg; p<0.001), but similar neurosensory sensitivity (median p(A): 0.5 vs 0.5; p = 0.69; 42.6% vs 42.9% were able to discriminate between the stimuli better than chance) and a greater tendency to report pain (median report criterion: 4.0 ("mild" pain) vs 5.2 ("weak" pain); p = 0.003). AML pain thresholds were not correlated with neurosensory sensitivity (r = -0.13; p = 0.14), but were strongly correlated with report criterion (r = 0.67; p<0.0001). Report criterion was inversely correlated with BSI somatisation (r = -0.26; p = 0.001) and BSI global score (r = -0.18; p = 0.035). Similar results were seen for the non-painful sensation of urgency. CONCLUSION: Increased colonic sensitivity in IBS is strongly influenced by a psychological tendency to report pain and urge rather than increased neurosensory sensitivity.

Functional gastrointestinal disorders: an update for the psychiatrist.

Functional gastrointestinal disorders (FGID) are common conditions, with well-established diagnostic criteria. They are associated with impaired health-related quality of life and increased societal and healthcare costs. Their symptoms are probably related to altered 5-HT transmission and central processing of noxious visceral stimuli. Evaluation and treatment are best formulated using a biopsychosocial model that integrates gut function with psychosocial assessment. Psychological therapies may improve overall well-being and appear to help patients without significant psychiatric comorbidity. Antidepressants help comorbid anxiety and depressive disorders and have primary efficacy in improving the symptoms of FGID. Finally, there is a need for greater involvement of psychiatrists in both the evaluation and treatment of patients with FGID as well as the education and training of practitioners caring for these patients.

Age, specialty, and practice setting predict gastroesophageal reflux disease prescribing behavior.

BACKGROUND: Gastroesophageal reflux disease (GERD) affects more than 40% of adults in the United States each month. Although the economic costs of treating this disorder are enormous, the attitudes and prescribing preferences of physicians who treat patients with GERD are not well known. This study was undertaken to determine physician prescribing practices in the treatment of GERD. METHODS: A questionnaire was mailed to 687 randomly selected, practicing gastroenterologists, internists, and family physicians in the State of Maryland. Each questionnaire was identical and contained 7 questions designed to elicit demographic data (age, sex, degree, specialty, practice setting, years in practice, community served), and 16 questions related to the evaluation and treatment of GERD. RESULTS: A total of 214 completed questionnaires were returned (31.1%), nearly equally distributed among the three different specialty groups. A total of 82% of the respondents were male; 60% of the respondents had practiced more than 15 years, and 6% had practiced 4 years or less. Older physicians prescribed proton pump inhibitors more often than younger physicians for mild or intermittent GERD symptoms. Physicians in an academic setting were more likely to use step-down therapy in patients with well-controlled GERD symptoms than were HMO-employed physicians. Family physicians requested a barium swallow in the evaluation of uncomplicated GERD more frequently than did gastroenterologists or internists. Gastroenterologists were more likely than family physicians and internists to recommend upper endoscopy for GERD patients with warning symptoms and for patients with long-standing reflux disease. CONCLUSIONS: Age, specialty, number of years in practice, and practice setting significantly influence how physicians evaluate and treat patients with GERD. Educational efforts to improve the evaluation and treatment of patients with GERD may require different strategies for different types of healthcare providers.

Cilansetron.

Irritable bowel syndrome is an extremely common disorder affecting approximately 10-20% of the population of North America and Europe. This disorder is characterized by abdominal pain and altered bowel habit. The altered bowel habit can take a number of forms. These include a predominant diarrhea form, a form with constipation and one in which patients alternate between diarrhea and constipated forms of the disorder. Irritable bowel syndrome to date has not been associated with any excess mortality. However, the morbidity associated with irritable bowel syndrome is quite high. This mainly takes on the form of impairment in health-related quality of life, interference with activities of daily living and a considerable degree of human suffering. Likewise, the economic impact of irritable bowel syndrome is not trivial and has been estimated to be between US$20 to 30 billion in the United States alone. In an effort to address this common disabling disorder, a number of new drugs have been developed. One of the latest is cilansetron, which is a competitive type 3 serotonin (5-HT3) receptor antagonist. In phase III trials, cilansetron has been shown to be efficacious for the relief of a wide spectrum of symptoms related to irritable bowel syndrome with diarrhea both in male and female patients. By and large, cilansetron is extremely well tolerated and highly efficacious. The most common side effect of cilansetron is constipation, which is seen in 3-12% of subjects at 6 months. Ischemic colitis, a side effect associated with previous drugs of this class, has been seen in eight subjects (six women and two men) to date. All of these ischemic colitis events have been self-limited and did not require surgery. Because of its high degree of efficacy, the fact that it is well tolerated by the overwhelming majority of patients and that it shows efficacy in both genders, cilansetron represents a major advance in the treatment of irritable bowel syndrome with diarrhea predominance.