Quality Gaps in Management of Acute Pancreatitis: A Tertiary Care Center Experience.

OBJECTIVES: Acute pancreatitis (AP) is a leading cause of inpatient care among gastrointestinal conditions. Our study compares the management of AP and adherence to guidelines among teaching medicine, nonteaching medicine, and surgical services within the same center. METHODS: We performed a retrospective chart review of AP patients admitted to our center between January 2016 and January 2017 and analyzed the clinical and epidemiological data. RESULTS: Of 115 patients, 65% were admitted to medicine (IM), and 35% were admitted to surgery. Mean age was 53.9 (standard deviation [SD], 15) years, and 52% were males; 38.6% (n = 29) of IM patients were prescribed lactated Ringer's solution for fluid resuscitation (mean rate of 153 [SD, 44.98] mL/h on teaching and 113 [SD, 43.56] mL/h on the nonteaching service). Antibiotics were prescribed to 22.6% (n = 17) of IM patients. On the surgical service, 77.5% of patients were prescribed lactated Ringer's solution for fluid resuscitation (mean rate of 108.25 [SD, 1.19] mL/h); 52.5% of patients received antibiotics. CONCLUSIONS: Adherence to guidelines for management of AP is inadequate, and nonuniformity exists across different services within the same institution. There is a need for quality improvement initiatives.

Risk of de-novo inflammatory bowel disease among obese patients treated with bariatric surgery or weight loss medications.

BACKGROUND: An association between bariatric surgery and development of de-novo inflammatory bowel disease (IBD) has been observed. AIM: To evaluate further the association among bariatric surgery, weight loss medications, obesity and new-onset IBD. METHODS: Using Explorys, a population-based Health Insurance Portability and Accountability Act compliant database, we estimated the prevalence of de-novo IBD among patients treated with bariatric surgery (Roux-en-Y gastrojejunostomy, laparoscopic sleeve gastrectomy or gastric banding) (n = 60 870) or weight loss medications (orlistat, phentermine/topiramate, lorcaserin, bupropion/naltrexone and liraglutide) (n = 193 790) compared with obese controls (n = 5 021 210), between 1999 and 2018. RESULTS: The prevalence of de-novo IBD was lower among obese patients exposed to bariatric surgery (7.72 per 1000 patients) or weight loss medications (7.22 per 1000 patients) compared with patients with persistent obesity not exposed to these interventions (11.66 per 1000 patients, P < 0.0001). The risk reduction for de-novo IBD was consistent across bariatric surgeries and weight loss medications with the exception of orlistat which was not associated with a reduction in risk for de-novo IBD compared with the persistent obese control cohort. CONCLUSION: Obese patients undergoing treatment with bariatric surgery or weight loss medications are at a lower risk for developing de-novo IBD compared with persistently obese controls not exposed to these interventions. These data suggest that obesity and ineffective management of obesity are risk factors for de-novo IBD. Further research is needed to confirm these observations and understand potential mechanisms.

Old vs new: Risk factors predicting early onset colorectal cancer.

BACKGROUND: Colorectal cancer (CRC) is the second leading cause of all cancer related deaths in the United States and Europe. Although the incidence has been decreasing for individuals' ≥ 50, it has been on the rise for individuals < 50. AIM: To identify potential risk factors for early-onset CRC. METHODS: A population-based cohort analysis using a national database, Explorys, screened all patients with an active electronic medical record from January 2012 to December 2016 with a diagnosis of CRC. Subgroups were stratified based on age (25 - 49 years vs ≥ 50 years). Demographics, comorbidities, and symptom profiles were recorded and compared between both age groups. Furthermore, the younger group was also compared with a control group consisting of individuals aged 25-49 years within the same timeframe without a diagnosis of CRC. Twenty-data points for CRC related factors were analyzed to identify potential risk factors specific to early-onset CRC. RESULTS: A total of 68860 patients were identified with CRC, of which 5710 (8.3%) were younger than 50 years old, with 4140 (73%) between 40-49 years of age. Multivariable analysis was reported using odds ratio (OR) with 95%CI and demonstrated that several factors were associated with an increased risk of CRC in the early-onset group versus the later-onset group. These factors included: African-American race (OR 1.18, 95%CI: 1.09-1.27, P < 0.001), presenting symptoms of abdominal pain (OR 1.82, 95%CI: 1.72-1.92, P <0.001), rectal pain (OR 1.50, 95%CI: 1.28-1.77, P < 0.001), altered bowel function (OR 1.12, 95%CI: 1.05-1.19, P = 0.0005), having a family history of any cancer (OR 1.78, 95%CI: 1.67-1.90, P < 0.001), gastrointestinal (GI) malignancy (OR 2.36, 95%CI: 2.18-2.55, P < 0.001), polyps (OR 1.41, 95%CI: 1.08-1.20, P < 0.001), and obesity (OR 1.14, 95%CI: 1.08-1.20, P < 0.001). Comparing the early-onset cohort versus the control group, factors that were associated with an increased risk of CRC were: male gender (OR 1.34, 95%CI: 1.27-1.41), P < 0.001), Caucasian (OR 1.48, 95%CI: 1.40-1.57, P < 0.001) and African-American race (OR 1.25, 95%CI: 1.17-1.35, P < 0.001), presenting symptoms of abdominal pain (OR 4.73, 95%CI: 4.49-4.98, P < 0.001), rectal pain (OR 7.48, 95%CI: 6.42-8.72, P < 0.001), altered bowel function (OR 5.51, 95%CI: 5.19-5.85, P < 0.001), rectal bleeding (OR 9.83, 95%CI: 9.12-10.6, P < 0.001), weight loss (OR 7.43, 95%CI: 6.77-8.15, P < 0.001), having a family history of cancer (OR 11.66, 95%CI: 10.97-12.39, P < 0.001), GI malignancy (OR 28.67, 95%CI: 26.64-30.86, P < 0.001), polyps (OR 8.15, 95%CI: 6.31-10.52, P < 0.001), tobacco use (OR 2.46, 95%CI: 2.33-2.59, P < 0.001), alcohol use (OR 1.71, 95%CI: 1.62-1.80, P < 0.001), presence of colitis (OR 4.10, 95%CI: 3.79-4.43, P < 0.001), and obesity (OR 2.88, 95%CI: 2.74-3.04, P < 0.001). CONCLUSION: Pending further investigation, these potential risk factors should lower the threshold of suspicion for early CRC and potentially be used to optimize guidelines for early screening.

Defining Pancreatitis as a Risk Factor for Pancreatic Cancer: The Role, Incidence, and Timeline of Development.

OBJECTIVES: Acute and/or chronic pancreatitis has been implicated as an important risk factor for pancreatic cancer; however, the incidence and temporal relationship of pancreatitis before pancreatic cancer diagnosis are unclear. We aim to understand the role and incidence of pancreatitis temporally with the development of pancreatic cancer. METHODS: A population-based study was used to investigate a temporal relationship between pancreatitis and pancreatic cancer diagnoses. Intervals of 3, 6, 12, 24, and 36 months were developed. Demographical data including age, sex, and race were also recorded and analyzed. RESULTS: A total of 50,080 patients were found to have a diagnosis of pancreatic cancer, of which 7420 (14.8%) had prior diagnoses of pancreatitis. Of those, 92% were between the ages of 40 and 89 years. African Americans had a higher rate of pancreatitis before cancer diagnosis when compared with whites (21.2% vs 14.8%, P < 0.0001). Further analysis revealed that pancreatitis occurred in 81.3% of patients 3 months before a diagnosis of pancreas cancer and 98.9% had established diagnoses of pancreatic cancer within 3 years. CONCLUSIONS: Screening of patients older than 40 years who have pancreatitis and unclear etiology of pancreatitis may be warranted, especially in African Americans and male individuals.

Fecal microbiota transplantation in recurrent Clostridium difficile infection: A retrospective single-center chart review.

BACKGROUND AND AIM: Fecal microbiota transplantation (FMT) has been proposed as a treatment option for patients with recurrent Clostridium difficile (C. difficile) infection but remains a novel option. We examined if FMT is an effective means of treating recurrent C. difficile infection. METHODS: A retrospective review of 35 patients who underwent FMT was completed. Demographics and other variables, including the use of proton pump inhibitor therapy and history of inflammatory bowel disease, were collected. RESULTS: Twenty-five patients (71.4%) belonged to a high-risk population (working in a hospital setting, rehabilitation center, or nursing facility) and a total of 74.3% of patients (n = 26 patients) had no history of proton pump inhibitor use. Twenty-five patients (71.4%) had used metronidazole prior to transplantation, 35 patients (100%) had used vancomycin, and 7 patients (20%) had used fidaxomicin for prior infection. Four patients (11.4%) had used all three antibiotics during prior treatment. Of the eight patients who had a history of inflammatory bowel disease, six (75%) experienced resolution of symptoms after transplantation. A total of 30 patients (85.7%) had resolution of their symptoms 6-8 weeks' posttransplant, while 5 patients (14.3%) continued to have symptoms. CONCLUSIONS: Our retrospective chart review supports that patients benefit from FMT in the setting of recurrent C. difficile infection.

College inflammatory bowel disease (C-IBD) day: a targeted approach to shared decision-making in college age students with IBD-a 2-year pilot project.

BACKGROUND: Adherence to treatment is a key therapeutic goal in chronic disorders including diabetes, inflammatory bowel disease (IBD), and hypertension. Non-adherence has been associated with increased health care costs. Previous studies have evaluated adherence to treatment in inflammatory bowel disease, as well as predictors of non-adherence. Higher belief of necessity for medications and membership of IBD patient organizations have been associated with higher medication adherence. AIM: This study aimed to identify patient reported factors that influence understanding of IBD in college age patients with IBD. METHODS: We conducted questionnaire based survey among a group of college age patients with IBD who attended a structured program. The program consisted of a clinical appointment with an IBD physician, lecture by an IBD physician, followed by interactive segment between patients. Educational material was available for patients to review. In addition, opportunity was given to patients to share their story and ask questions in a safe environment. RESULTS: A total of 26 patients participated in the two C-IBD sessions over a 2-year period. Twenty-three were enrolled in college, 1 was a recent graduate, and 2 were of college age but not enrolled. All patients thought the program was beneficial, 96% rated the overall experience as "awesome" or "very good." Seventy-six percent of patients reported sharing their story as the most beneficial. Only 19% found the physician lecture beneficial. CONCLUSION: A targeted approach to a vulnerable population with IBD is an additional useful tool in improving understanding of IBD. This may lead to improved compliance with management plans.

Public reporting of colonoscopy quality is associated with an increase in endoscopist adenoma detection rate.

BACKGROUND: Colonoscopy is the predominant method for colorectal cancer screening in the United States. Previous studies have documented variation across physicians in colonoscopy quality as measured by the adenoma detection rate (ADR). ADR is the primary quality measure of colonoscopy examinations and an indicator of the likelihood of subsequent colorectal cancer. There is interest in mechanisms to improve the ADR. In Central Illinois, a local employer and a quality improvement organization partnered to publically report physician colonoscopy quality. OBJECTIVE: We assessed whether this initiative was associated with an improvement in the ADR. DESIGN: We compared ADRs before and after public reporting at a private practice endoscopy center with 11 gastroenterologists in Peoria, Illinois, who participated in the initiative. To generate the ADR, colonoscopy and pathology reports from examinations performed over 4 years at the endoscopy center were analyzed by using previously validated natural language processing software. SETTING: A central Illinois endoscopy center. RESULTS: The ADR in the pre-public reporting period was 34.3% and 39.2% in the post-public reporting period (an increase of 4.9%, P < .001). The increase in the right-sided ADR was 5.1% (P < .01), whereas the increase in the left-sided ADR was 2.1% (P < .05). The increase in the ADR was 7.8% for screening colonoscopies (P < 0.05) and 3.5% for nonscreening colonoscopies (P < .05). All but 1 physician's ADR increased (range -2.7% to 10.5%). There was no statistically significant change in the advanced ADR (increase of 0.8%, P = .22). LIMITATIONS: There was no concurrent control group to assess whether the increased ADR was due to a secular trend. CONCLUSION: A public reporting initiative on colonoscopy quality was associated with an increase in ADR.

Prophylaxis with ertapenem in patients with obstructive jaundice undergoing endoscopic retrograde cholangiopancreatography: safety, efficacy, and biliary penetration.

BACKGROUND: Cholangitis and biliary sepsis are rare but serious complications of endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study is to investigate the safety, efficacy, and biliary penetration of ertapenem, a newer carbapenem with a long half-life and broad-spectrum antimicrobial activity, for ERCP prophylaxis. METHODS: Patients with obstructive jaundice without cholangitis received a single dose of ertapenem equal to 1 gram intravenously prior to ERCP. A 2-3 mL bile sample was collected after cannulation and prior to contrast injection. Patients were observed for 72 hours for cholangitis or drug-related adverse events. Biliary ertapenem levels were measured using high-performance liquid chromatography (HPLC). RESULTS: Twenty-eight patients (ages 18-87 years, M/F ratio 1:1) were enrolled. Seven had no cholestasis and were included to study ertapenem penetration in unobstructed biliary trees. Cannulation was achieved in all patients. One patient (3.6%) with persistent intrahepatic stones developed cholangitis. No drug-related adverse events were noted. The mean time from ertapenem administration to bile collection was 60 ± 24 minutes. There was a significant negative correlation between serum bilirubin and biliary ertapenem levels (r = -0.542, P = 0.003) with the highest level (6.25 µg/mL) noted in unobstructed biliary systems. CONCLUSION: Ertapenem appears to be a safe and effective prophylaxis in patients with obstructive jaundice undergoing ERCP despite a limited biliary penetration in patients with high-grade obstruction.

A randomized controlled trial of imipramine in patients with irritable bowel syndrome.

AIM: To study the efficacy of low-dose imipramine in relieving symptoms associated with the irritable bowel syndrome (IBS). METHODS: A randomized, double-blind trial of 25 mg imipramine vs matched placebo for 12 wk was performed. Doubling the dose was allowed once at week 2 in case of an unsatisfactory early response. Primary efficacy variables were subjective global symptom relief and quality of life (QoL) using SF-36 at week 12. RESULTS: One hundred and seven patients were enrolled by advertisement or referral by general practitioners and 56 (31 imipramine: 25 placebo) completed the 16-wk study. Baseline characteristics were comparable. A high overall dropout rate was noted in the imipramine and placebo arms (47.5% vs 47.9%, P > 0.05), a mean of 25.0 and 37.4 d from enrollment, respectively (P < 0.05). At the end of 12 wk, there was a significant difference in global symptom relief with imipramine over placebo (per-protocol: 80.6% vs 48.0%, P = 0.01) and a trend on intent-to-treat (ITT) analysis (42.4% vs 25.0%, P = 0.06). This improvement was evident early and persisted to week 16 (P = 0.024 and 0.053 by per-protocol and ITT analyses, respectively). Mean cumulative and component-specific SF-36 scores improved in the imipramine group only (per-protocol, P < 0.01). Drug-related adverse events leading to patient dropout were more common in the imipramine group (25.4% vs 12.5%, P > 0.05). CONCLUSION: Imipramine may be effective in the treatment of IBS patients and is associated with improved QoL. Careful patient selection, initiation of a low dose with gradual escalation and monitoring for side effects may result in an improved therapeutic response.

Gastrointestinal bleeding in the setting of anticoagulation and antiplatelet therapy.

GOAL: To review the literature on the significance, risk factors, and management of occult and gross gastrointestinal (GI) bleeding in patients on antiplatelets and/or anticoagulants. STUDY: Relevant original and review articles and their bibliographies were analyzed. Estimates of risks and therapeutic outcomes were obtained from randomized trials, whereas risk factor identification was gathered from cross-control and prospective cohort studies. RESULTS: Antiplatelets and anticoagulants do not diminish the positive predictive value of fecal occult blood testing to find GI pathology. They increase the risk of gross GI bleeding, and predictors of hemorrhage include history of GI bleeding or ulcer disease, higher intensity of anticoagulation, combination therapy, and presence of comorbid conditions. A bleeding site is identified in most patients with peptic ulcer being the most common. In case of significant bleeding, complete or partial reversal of anticoagulation is undertaken on the basis of the balance of risks between bleeding and thromboembolic events. Early endoscopy can reveal lesions requiring endoscopic hemostasis, which can be performed in the setting of low-intensity anticoagulation. In patients with history of peptic disease or bleeding from an acid-related lesion, proton-pump inhibitors and Helicobacter pylori eradication reduce the risk of upper GI bleeding even when antiplatelet therapy is continued. CONCLUSIONS: Predictors of bleeding on antiplatelets and/or antithrombotics therapy have been identified, but formulation and validation of a GI bleeding index for stratification of risk in individual patients is suggested. Reversal of anticoagulation in bleeding patients is associated with a low risk of thromboembolic events and permits the performance of diagnostic and therapeutic endoscopy. Proton-pump inhibitors and H. pylori eradication reduce the risk of rebleeding in those with acid-related disease.

A randomized, controlled, double-blind trial of the adjunct use of tegaserod in whole-dose or split-dose polyethylene glycol electrolyte solution for colonoscopy preparation.

BACKGROUND: Problems of compliance, quality, and safety of colon preparation regimens have prompted continued investigation with alternative forms of cleansing. OBJECTIVE: To evaluate the efficacy of tegaserod as an adjunct to a polyethylene glycol electrolyte solution (PEG-E), given as a whole dose or split dose, in colonoscopy preparation. DESIGN: Randomized, placebo-controlled, double-blind trial. SETTING: A single university-based hospital. PATIENTS: Patients who were undergoing elective colonoscopy. INTERVENTIONS: A 4-arm randomization scheme that compared tegaserod with a placebo, each with whole-dose or split-dose PEG-E preparation. MAIN OUTCOME MEASUREMENTS: Efficacy of colon cleansing was the primary outcome. Secondary outcomes included adherence, tolerability, adverse effects, and patient perceptions of their preparation quality. RESULTS: A total of 382 patients completed the trial. Patients who received the split-dose preparation had significantly better colon cleansing than those who received the whole-dose preparation (88.9% vs 42.6%, P < .001). The addition of tegaserod did not significantly improve the overall colonoscopy preparation quality compared with a placebo. However, there were fewer poor preparations in the whole-dose PEG-E group (12.4% vs 1.1%, P = .002, Bonferroni correction removes significance) and more excellent preparations in the split-dose group (53.3% vs 38.3%, P = .035, Bonferroni correction removes significance) in favor of tegaserod. Interobserver and intraobserver variability analysis showed substantial agreement among endoscopists. Adherence was significantly lower in the whole-dose group versus the split-dose PEG-E group (68.8% vs 91%, P < .001), independent of the use of tegaserod. Adverse effects were not different between study groups. LIMITATIONS: A 4-arm randomization and the single-center nature of the study. CONCLUSIONS: Tegaserod has a marginal effect on the quality of colonoscopy preparation when used as an adjuvant to PEG-E. The split-dose PEG-E was superior to the whole-dose PEG-E and resulted in better colon cleansing, adherence, and tolerance.

Lidocaine lollipop as single-agent anesthesia in upper GI endoscopy.

BACKGROUND: Conscious sedation is usually achieved during EGD by a combination of intravenous benzodiazepines and opiates; however, these have potential serious adverse effects. The addition of topical oropharyngeal anesthetics such as lidocaine may be useful. Recent data suggest that the administration of topical lidocaine by means of a lollipop is effective for endotracheal intubation and bronchoscopy. OBJECTIVE: Our purpose was to evaluate the safety and efficacy of a lidocaine lollipop as single-agent anesthesia for EGD and to determine whether its use reduces the need for intravenous sedatives and analgesics. DESIGN: Single-blinded, randomized, prospective study. SETTING: University hospital. PATIENTS: 50 patients undergoing diagnostic EGD. INTERVENTIONS: Patients were randomized to either lidocaine lollipop or lidocaine spray. Intravenous meperidine and midazolam were administered during the procedure as needed. MAIN OUTCOME MEASUREMENTS: The success and safety of local anesthesia by lidocaine lollipop in addition to the need for intravenous sedation. RESULTS: Patients were equally randomized between the lollipop and the spray groups. The lollipop group had less gag reflex, accommodated scope introduction more, and tolerated the procedure better. Thirty-two percent of patients receiving the lollipop required sedation compared with 96% of patients in the spray group (P < .001). The majority in the lollipop group were satisfied with their mode of anesthesia compared with the spray group. CONCLUSIONS: Lidocaine lollipop is a promising form of local oropharyngeal anesthesia for EGD. Its use resulted in sparing the use of intravenous sedation. It is well tolerated and safe and may be particularly important in the elderly, patients with comorbidities, and office-based endoscopy.

Prevalence of endoscopically identified heterotopic gastric mucosa in the proximal esophagus: endoscopist dependent?

GOALS: The aim of this study is to determine the prevalence of heterotopic gastric mucosa in the proximal esophagus (HGMPE) and whether thorough endoscopic search may influence such prevalence. BACKGROUND: Heterotopic gastric mucosa in the esophagus (sometimes known as inlet patch) refers to a discrete area of gastric mucosa, with a spherical or ellipsoid configuration, that is typically located in the proximal esophagus. The prevalence of endoscopically diagnosed HGMPE varies from 0.1% to 10%. Endoscopic detection may be difficult as HGMPE is often located at or just below the upper esophageal sphincter. It might be associated with severe complications such as bleeding, perforation, fistula, and stricture formation, in addition to the development of adenocarcinoma. STUDY: During a 2-year period, 455 consecutive patients with various gastrointestinal complaints underwent esophagogastroduodenoscopy by a single endoscopist (group 1). This endoscopist paid special attention to detecting HGMPE by thoroughly examining the proximal esophagus upon withdrawal of the endoscope. During the same period of time, endoscopy reports of 472 patients who underwent esophagogastroduodenoscopy in the same hospital by 3 other endoscopists were retrospectively reviewed (group 2). These endoscopists were aware of the existence of the HGMPE and reported that the presence of HGMPE would be included as an endoscopic finding in their reports. RESULTS: In the first group, HGMPE was identified in 12 out of 455 patients (2.6%). Whereas in the second group, only 2 out of 472 patients (0.4%) had reports identifying HGMPE (P<0.01). CONCLUSIONS: Endoscopic detection of HGMPE is influenced by the endoscopist's thorough search of this entity, and thus, more time devoted to such a search may lead to higher detection rates.

Clinical epidemiology of inflammatory bowel disease in Lebanon.

BACKGROUND: The objectives of this study were to determine the prevalence and incidence of inflammatory bowel disease (IBD) in a representative Lebanese cohort and to describe practice prevalence trends, disease characteristics, and impact on quality of life (QoL) of IBD patients in Lebanon. METHODS: All of a university-based health program's 2000-2004 computerized records that listed a diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) were reviewed. In addition, data on patients seen in the gastroenterology clinics and data from the IBD registry at the American University of Beirut Medical Center (AUBMC) from the same period were analyzed. RESULTS: Of 15,073 insured individuals, 8 had a diagnosis of CD and 16 of UC, giving an age-adjusted prevalence of 53.1 per 100,000 people for CD and 106.2 per 100,000 people for UC. The mean age at diagnosis for patients with CD and UC was 28.8 +/- 11.1 and 32.0 +/- 13.4 years, respectively, and there was a slight female predominance. The mean annual incidence was 4.1 per 100,000 people for UC and 1.4 per 100,000 people for CD (range, 0-6.9/100,000 for both). Of the 10,383 patients seen in the gastroenterology clinic from 2000 to 2004, 251 (2.4%) had IBD (142 UC, 100 CD, and 9 indeterminate), a ratio that trended upward over time (range, 1.8%-2.7%). The median IBD Quality-of-Life (IBDQ) questionnaire score was 124.9 +/- 30.5, indicating that the disease had a moderately severe impact on QoL. CONCLUSIONS: The prevalence of IBD in this representative Lebanese cohort falls in the intermediate range of that reported for white populations in Europe and North America. Future studies are needed to examine local risk factors, disease genotypes and phenotypes, and epidemiologic time trends. The psychosocial burden of IBD in Lebanon appears significant.