In-hospital weekend outcomes in patients diagnosed with bleeding gastroduodenal angiodysplasia: a population-based study, 2000 to 2011.

BACKGROUND AND AIMS: GI angiodysplastic (GIAD) lesions are an important cause of blood loss throughout the GI tract, particularly in elderly persons. The aim of this study was to determine whether mortality rates in patients with GIAD were higher for weekend compared with weekday hospital admissions. METHODS: We performed a retrospective study using the National Inpatient Sample database from 2000 to 2011 including inpatients with an International Classification of Diseases, Ninth Revision, Clinical Modification code for gastrointestinal GIAD (code 537.82 or 537.83). We assessed rates of delayed endoscopy (examinations performed >24 hours after admission), intensive care unit (ICU) admissions, and in-hospital mortality rates. Bivariate and multivariate logistic regression analyses were performed to identify risk factors for mortality. RESULTS: There were 85,971 discharges for GIAD between 2000 and 2011, of which 69,984 (81%) were weekday hospital admissions and 15,987 (19%) were weekend admissions. Patients with weekend versus weekday admissions were more likely to undergo delayed endoscopic examination (35% vs 26%, P ≤ .0001). Mortality rates were higher for patients with weekend admissions (2% vs 1%, P = .0002). The adjusted odds ratio (aOR) for inpatient mortality associated with weekend admissions was elevated (2.4; 95% confidence interval [CI], 1.5-3.9; P = .0005). Rates of delayed endoscopic examinations were lower in patients with higher socioeconomic status (aOR = 0.77; 95% CI, 0.68-0.88). ICU admission rates were higher for weekend compared with weekday admissions (8% vs 6%, P = .004). The presence of a delayed endoscopic examination was associated with an increased length of stay of 1.3 days (95% CI, 1.2-1.4 days). CONCLUSIONS: Weekend admissions for angiodysplasia were associated with higher odds of mortality, ICU admissions, higher rates of delayed endoscopic procedures, longer lengths of stay, and higher hospital charges.

Patient burden and patient preference: comparing magnetic resonance enteroclysis, capsule endoscopy and balloon-assisted enteroscopy.

BACKGROUND AND AIM: We aimed to prospectively determine patient burden and patient preference for magnetic resonance enteroclysis, capsule endoscopy and balloon-assisted enteroscopy in patients with suspected or known Crohn's disease (CD) or occult gastrointestinal bleeding (OGIB). METHODS: Consecutive consenting patients with CD or OGIB underwent magnetic resonance enteroclysis, capsule endoscopy and balloon-assisted enteroscopy. Capsule endoscopy was only performed if magnetic resonance enteroclysis showed no high-grade small bowel stenosis. Patient preference and burden was evaluated by means of standardized questionnaires at five moments in time. RESULTS: From January 2007 until March 2009, 76 patients were included (M/F 31/45; mean age 46.9 years; range 20.0-78.4 years): 38 patients with OGIB and 38 with suspected or known CD. Seventeen patients did not undergo capsule endoscopy because of high-grade stenosis. Ninety-five percent (344/363) of the questionnaires were suitable for evaluation. Capsule endoscopy was significantly favored over magnetic resonance enteroclysis and balloon-assisted enteroscopy with respect to bowel preparation, swallowing of the capsule (compared to insertion of the tube/scope), burden of the entire examination, duration and accordance with the pre-study information. Capsule endoscopy and magnetic resonance enteroclysis were significantly preferred over balloon-assisted enteroscopy for clarity of explanation of the examination, and magnetic resonance enteroclysis was significantly preferred over balloon-assisted enteroscopy for bowel preparation, painfulness and burden of the entire examination. Balloon-assisted enteroscopy was significantly favored over magnetic resonance enteroclysis for insertion of the scope and procedure duration. Pre- and post-study the order of preference was capsule endoscopy, magnetic resonance enteroclysis and balloon-assisted enteroscopy. CONCLUSION: Capsule endoscopy was preferred to magnetic resonance enteroclysis and balloon-assisted enteroscopy; it also had the lowest burden. Magnetic resonance enteroclysis was preferred over balloon-assisted enteroscopy for clarity of explanation of the examination, bowel preparation, painfulness and burden of the entire examination, and balloon-assisted enteroscopy over magnetic resonance enteroclysis for scope insertion and study duration.

Faecal elastase 1 concentration is a marker of duodenal enteropathy.

BACKGROUND: Measurement of faecal elastase (FE1) is used widely to screen for pancreatic exocrine insufficiency (PI). FE1 does not allow differentiation of primary from secondary PI. AIMS: To investigate the relation between duodenal morphology and FE1 in children with secondary PI resulting from primary gastrointestinal diseases. METHODS: A group of 51 children underwent small intestinal biopsy and FE1 measurement. Villus to crypt ratio (VCR) and inflammation within the lamina propria of duodenal mucosal biopsy specimens were scored and compared with FE1 values. RESULTS: In 51 children from nine diagnostic categories, a highly significant correlation between FE1 and both duodenal morphology and inflammation was found. CONCLUSION: Small bowel enteropathy is associated with low FE1 concentrations, indicative of secondary exocrine pancreatic insufficiency.

Disease-specific outcomes assessment for gastrointestinal bleeding.

Over the past twenty years, outcomes research has emerged as a methodology to systematically evaluate medical practice and outcomes of care. The assessment of outcomes in clinical practice can improve the quality of care delivered to patients. More specifically, improved quality can be realized by identifying endoscopic practices that are cost-efficient, by reducing the variability of endoscopic interventions, and by eliminating those endoscopic interventions that appear to be ineffective. The aims of this article are to provide practical information to the practicing endoscopist on which outcomes are important to measure in patients with gastrointestinal hemorrhage, and to detail methods of how to accomplish this.

Positive predictive value of ICD-9th codes for upper gastrointestinal bleeding and perforation in the Sistema Informativo Sanitario Regionale database.

We identified patients whose records in the Sistema Informativo Sanitario Regionale database in the Italian region of Friuli-Venezia Giulia showed a code of upper gastrointestinal bleeding (UGIB) and perforation according to codes of the International Classification of Diseases (ICD)-9th revision. The validity of site- and lesion-specific codes (531 to 534) and nonspecific codes (5780, 5781, and 5789) was ascertained through manual review of hospital clinical records. The initial group was made of 1779 potential cases of UGIB identified with one of these codes recorded. First, the positive predictive values (PPV) were calculated in a random sample. As a result of the observed high PPV of 531 and 532 codes, additional hospital charts were solely requested for all remaining potential cases with 533, 534, and 578 ICD-9 codes. The overall PPV reached a high of 97% for 531 and 532 site-specific codes, 84% for 534 site-specific codes, and 80% for 533 lesion-specific codes, and a low of 59% for nonspecific codes. These data suggest a considerable research potential for this new computerized health care database in Southern Europe.

Valoración de la patología esofagogastroduodenal en pacientes portadores de colecistopatía litiásica / Evaluation of esophafogastroduodenal pathology in patients with gallstone disease

Se realiza una investigación prospectiva desde mayo de 1991 a octubre de 1992 en 40 pacientes portadores de colecistopatía litiásica, con el fin de determinar los posibles cambios acaecidos en el sector esofagogastroduodenal, posteriores a la colecistectomía. Se realizaron en todos los pacientes: historia clínica tipo, ecografía, colecistograma, fibroesofagogastroduodenoscopía con biopsia esofágica y antral en el preoperatorio. El seguimiento se llevó a cabo con control clínico y endoscópico con biopsia esofágica y antral, 6 meses después de la colecistectomía. En los resultados se ve un notorio aumento de la gastritis crónica superficial, esofagitis, gastritis erosiva, gastritis atrófica y metaplasia intestinal, tanto endoscópica como histológicamente, a pesar de que los pacientes mejoraron sus hábitos dietéticos y disminuyeron la ingesta de AINE en el posoperatorio. Se llega a la conclusión de que un alto número de pacientes portadores de colecistopatía litiásica tienen asociadas patologías de la esfera esofagogastroduodenal y que éstas se acentuaron luego de la colecistectomía. Esto nos induce a plantear que se deben agotar los recursos para su diagnóstico en el preoperatorio y su seguimiento en el posoperatorio

Primary panendoscopy.

Primary panendoscopy is defined as a limited-consultative, diagnostic, UGI endoscopic examination that provides, in non-critically ill patients with dyspeptic symptoms, an accurate and cost-effective alternative to the standard UGI x-ray examination. The procedure was instituted at St. Mary's Medical Center's hospital in February 1985. During the first 12 months, a total of 321 patients were examined: 212 inpatients and 109 outpatients. In those patients with complete information, primary panendoscopy changed the diagnosis in 67% and the treatment in 52%. As expected, the number of esophagogastroduodenoscopies decreased during this time, but the combined numbers of primary panendoscopies and esophagogastroduodenoscopies exceeded the projected increase of esophagogastroduodenoscopies. Similarly, the number of UGI x-ray examinations fell sharply. With a physician fee of $150.00 and a facility fee of $50.00, theoretical savings of some $117,000.00 to the patients were estimated. The authors conclude that primary panendoscopy provides a cost-effective and beneficial patient service that warrants broad consideration by gastroenterologists as they face the cost constraints being imposed within the health care system of the 1980s.

Upper gastrointestinal fibreoptic endoscopy experience in the Sudan. Analysis of 2500 endoscopies.

The results of 2500 upper gastrointestinal fibreoptic endoscopies carried out at Soba University Hospital, Khartoum, between January, 1980, and June, 1982, were reviewed. 42% of the patients had no disorder visible on endoscopy, 9% had oesophageal varices, 0.7% gastric ulcer, 17% duodenal ulcer, and 2% pyloric obstruction. Duodenal ulcer was seen more commonly in men (male/female ratio 4.5/1) and in young people. Endoscopy is a feasible procedure in developing countries. It is more informative and cheaper than barium meal radiology.

Evaluating the costs and benefits of a diagnostic technology: the case of upper gastrointestinal endoscopy.

Medical technology assessment has been proposed as a way to encourage more appropriate use of medical technologies, which may in turn lower medical care costs. The application to a diagnostic technology of techniques for medical technology assessment is discussed, using upper gastrointestinal endoscopy as an example. Several generic problems are often encountered when performing an assessment of a diagnostic technology. These problems include the need to weigh relatively concrete data on clinical and economic costs against less quantifiable data on the value of the information gained from the procedure. In the case of upper gastrointestinal endoscopy, data on morbidity (approximately two cases per 1,000 cases), mortality (approximately one case per 20,000 cases), changes (approximately +290 per procedure), and costs (between +69 and +128 per procedure) are relatively easily determined. Less easily calculated is the marginal diagnostic gain from endoscopies performed for the wide variety of conditions for which an endoscopy may be indicated. It is concluded that, in the case of diagnostic technologies, technology evaluations may be most useful as a heuristic tool. Because of the difficulty in weighing costs and benefits, however, formal evaluations of diagnostic technologies are not likely in the near future to contribute to medical care cost containment.

Problems in duodenogastric reflux assessment, using bile acid and lysolecithin measurement.

In 187 subjects with widely varying degrees of duodenogastric reflux, intragastric bile acid values were compared with reflux measurement by a biliary marker technique involving intragastric recovery of intravenously injected 14C-bile acids. Furthermore, bile acids were compared to lysolecithin in gastric aspirates. The biliary marker principle, as an indirect method, proved unreliable for assessing endogenous bile reflux. Direct analysis of intragastric duodenal contents, promising more accurate, and, in pathophysiological terms, more meaningful results, cannot rely only on bile acid analysis, since highly divergent lysolecithin values may occur. Thus, any sole acid quantification of reflux by indirect or direct methods will fail to qualify its cytotoxic potential.