Medical care setting is associated with survival in acute upper gastro-intestinal bleeding: A cohort study.

BACKGROUND: There are limited data on the effect of the medical care setting on survival in patients admitted with acute upper gastrointestinal bleeding. AIMS: To identify the organisational and care setting which provides the optimal survival in patients with acute upper gastrointestinal bleeding. METHODS: A retrospective observational study of administrative data from a cohort of patients admitted to a Regional or Local hospital, and cared for in a gastroenterology or general ward. PRIMARY OUTCOME: 30 day survival for non-variceal bleeding and 42 day survival for variceal bleeding. RESULTS: Out of 3368 patients, the source of bleeding was non-variceal in 2980 (88.5%). Survival, adjusted for clinical and organisational factors, was higher in patients admitted to a gastroenterology ward vs other wards (OR = 2.02 p < 0.0006). Management in a gastroenterology ward in a Regional hospital provided a higher survival rate (95.6% ±â€¯0.08) vs a non-gastroenterology ward in a Local hospital (92.9% ±â€¯0.05 p < 0.01) or a non-gastroenterology ward in a Regional hospital (89.5% ±â€¯0.01 p < 0.0001). Survival (94.0% ±â€¯1.6) in a Local hospital with a gastroenterology ward was significantly higher than in a Regional hospital without (89.5% ±â€¯1.1) p < 0.01. CONCLUSION: Survival was optimal for patients treated in a gastroenterology ward independently of Regional or Local hospital setting.

Escalas de predicción en el pronóstico del paciente con hemorragia digestiva alta no varicosa / Predicting scales for prognosis of patients with non-variceal upper gastrointestinal bleeding

La hemorragia digestiva alta no varicosa constituye una importante causa de morbilidad y mortalidad en el mundo. Para su manejo se ha impuesto la necesidad de usar escalas pronósticas para definir la conducta a seguir con un empleo óptimo de los recursos médicos, de manera tal que se garantice una asistencia de calidad al paciente. El objetivo del trabajo es realizar un resumen de los aspectos positivos y negativos de las escalas, relacionar los parámetros que contemplan y las posibilidades de su aplicación en Cuba. Se efectuó una búsqueda en los registros bibliográficos existentes de las bases de datos de PUBMED y EBSCO. Se utilizaron las palabras claves, en idiomas español e inglés: hemorragia digestiva alta no varicosa y escalas pronósticas. Se realizó una revisión de los diferentes modelos; se relacionaron a los autores principales de las escalas; se dividieron en preendoscópicas y endoscópicas y se caracterizaron las más utilizadas. La información recogida permitió obtener una visión general, al mostrar las diferentes variantes existentes y clasificar al paciente según el riesgo que presenta, de acuerdo con los índices pronósticos obtenidos después de la aplicación de la escala. Se concluye que las escalas pronósticas permiten evaluar la necesidad de intervención urgente, la probabilidad de sangrado, la necesidad de cirugía o la mortalidad aguda en la toma de decisiones médicas y su uso está en correspondencia con las particularidades de cada contexto.

The non-variceal upper gastrointestinal bleeding is a major cause of morbidity and mortality worldwide. The need for prognostic scales to define the course of action regarding the optimal use of medical resources has imposed, so that patient care quality is guaranteed. The aim of this paper is to go over the positive and negative aspects of the scales, to relate the parameters included and the possibilities of its application in Cuba. A search was conducted on existing bibliographic records in PubMed and EBSCO databases. Keywords in Spanish and English were used, such as non-variceal upper gastrointestinal bleeding, and prognostic scales. A review of different models was performed; the principal authors of the scales were related; scales were divided into pre-endoscopic and endoscopic and the most used were characterized. The information collected allowed for an overview, showing the various existing variants and classify patients according to risks, according to forecasts indices obtained after the scale application. It is concluded that the prognostic scales to assess the need for urgent intervention, the bleeding likelihood, surgery or acute mortality in medical decision making and their use is in line with each context particularities.

[Hygiene in endoscopy in clinic and practice 2013 in comparison with 2003--structure and process quality]. / Struktur- und Prozessqualität bei der Aufbereitung flexibler Endoskope in Klinik und Praxis in Frankfurt am Main--2013 im Vergleich zu 2003.

BACKGROUND: Endoscopy is an important part of modern medical diagnostics and therapy. The invasive procedures are however associated with a risk to transmit infections. Against this background the KRINKO has published the "Hygienic requirements for the reprocessing of flexible endoscopes and endoscopic accessories" in 2002 and has updated these recommendations in 2012. In 2003 and 2013 all gastroenterological facilities in Frankfurt am Main using flexible endoscopes were monitored for compliance with the recommendations. METHODS: The inspections were performed after prior notice by a staff member of the health authority using a checklist which had been developed on the basis of the current KRINKO recommendations. RESULTS: In both years all institutions performing endoscopic procedures were visited: 2003 15 hospitals and 23 practices; 2013 14 clinics and 10 practices. In 2013 (data for 2003 in brackets) 100 % (93 %) of the hospitals and 60 % (22 %) of practices reprocessed their endoscopes by automated methods. The appropriate reprocessing and filling of water bottles for rinsing the scope channels with sterile water and the sterilisation of accessories were satisfactorily performed in 2003 and 2013 by all hospitals. However in 2013 only 90 % (2003: 74 %) of the practices correctly reprocessed water bottles and 80 % (52 %) used sterile water for filling the bottle. In 2013 100 % (2003: 57 %) of the practices correctly sterilised accessory instruments, while 2 practices used disposable, i. e., single-use materials. In 2013 all institutions performed microbiological tests according to KRINKO recommendations, while in 2003 all hospitals but only 43 % of the practices could present such tests. DISCUSSION: While the gastroenterological departments of Frankfurt hospitals already complied with the KRINKO recommendations in 2003, the inspection of several practices in 2003 had revealed considerable shortcomings in the implementation of these recommendations. Subsequently the practices have improved their hygiene management.

Community contextual predictors of endoscopic colorectal cancer screening in the USA: spatial multilevel regression analysis.

BACKGROUND: Colorectal cancer (CRC) is the second leading cause of cancer death in the United States, and endoscopic screening can both detect and prevent cancer, but utilization is suboptimal and varies across geographic regions. We use multilevel regression to examine the various predictors of individuals' decisions to utilize endoscopic CRC screening. Study subjects are a 100% population cohort of Medicare beneficiaries identified in 2001 and followed through 2005. The outcome variable is a binary indicator of any sigmoidoscopy or colonoscopy use over this period. We analyze each state separately and map the findings for all states together to reveal patterns in the observed heterogeneity across states. RESULTS: We estimate a fully adjusted model for each state, based on a comprehensive socio-ecological model. We focus the discussion on the independent contributions of each of three community contextual variables that are amenable to policy intervention. Prevalence of Medicare managed care in one's neighborhood was associated with lower probability of screening in 12 states and higher probability in 19 states. Prevalence of poor English language ability among elders in one's neighborhood was associated with lower probability of screening in 15 states and higher probability in 6 states. Prevalence of poverty in one's neighborhood was associated with lower probability of screening in 36 states and higher probability in 5 states. CONCLUSIONS: There are considerable differences across states in the socio-ecological context of CRC screening by endoscopy, suggesting that the current decentralized configuration of state-specific comprehensive cancer control programs is well suited to respond to the observed heterogeneity. We find that interventions to mediate language barriers are more critically needed in some states than in others. Medicare managed care penetration, hypothesized to affect information about and diffusion of new endoscopic technologies, has a positive association in only a minority of states. This suggests that managed care plans' promotion of this cost-increasing technology has been rather limited. Area poverty has a negative impact in the vast majority of states, but is positive in five states, suggesting there are some effective cancer control policies in place targeting the poor with supplemental resources promoting CRC screening.

The impact of endoscopy and specialist care on 30-day mortality among patients with acute non-variceal upper gastrointestinal hemorrhage: an Italian population-based study.

OBJECTIVE: To analyze the effects of endoscopy and care in a gastroenterology ward on 30-day mortality among Italian patients hospitalized for acute non-variceal upper gastrointestinal hemorrhage (UGIH). METHODS: We conducted a population-based study based on administrative data contained in the Regional Hospital Information System (RHIS) for the Lazio Region (Italy). We identified all hospitalizations with a main diagnosis of UGIH during period 2000-2005. Discharge data were analyzed for procedures performed, ward where the patient was cared for, comorbidities, vital status at discharge. Vital status 30 days after admission was cross-checked with the Regional Registry of Causes of Death. Logistic regression models were performed taking into account patients' risk factors (OR and C.I. 95%). RESULTS: A total of 13,427 hospitalizations for UGIH (mean patient age, 68 years; 60% males) were identified. The 30-day mortality was 6.9%. Significantly lower rates were observed among hospitalizations that included endoscopy (OR 0.30, 95% C.I. 0.26-0.34), specialist care (OR 0.55, 95% C.I. 0.37-0.82), or both (OR 0.12, 95% C.I. 0.07-0.22). The protective effects of endoscopy and specialist care remained strong after adjustment for potential risk factors. CONCLUSIONS: Endoscopy, per se, reduces mortality among patients hospitalized for UGIH, and care in a gastroenterology ward may offer additional protective effects.

Prospective replacement of magnifying endoscopy by a newly developed endocytoscope, the 'GIF-Y0002'.

Endocytoscopy has the potential to reduce the need for histologic examination of biopsy specimens in cases of esophageal squamous cell carcinoma. Up to now, two types of endocytoscope have been used: the probe type and the integrated type. In this study we examined the utility of a newly developed endocytoscope, the 'GIF-Y0002,' which has a single lens allowing consecutive magnification from the conventional endoscopy level up to ×380. Using the GIF-Y0002, we examined 24 examples of normal esophageal mucosa to clarify the appearance of the microvasculature of the normal squamous epithelium in vivo. We also examined 11 cases of esophageal cancer in the same way, employing methylene blue as a vital dye to stain the surface cells. In normal squamous epithelium, we clarified the relationship between the subepithelial capillary network, IPCLs and subepithelial venules. With methylene blue staining, we observed typical squamous cells (low nuclear density and low N/C ratio without nuclear abnormality). When cancerous lesions were observed using lower-power magnification, we were able to visualize their microvascular architecture to the same extent as when conventional magnifying endoscopy was used. Furthermore, at higher magnification, we were able to visualize the features of blood flow in both superficial and advanced cancer. Methylene blue staining revealed an increase of nuclear density in all cases of cancer. The pathologist agreed to omit biopsy histology in 81.8% (9/11) of cancer cases considering the nuclear density and nuclear abnormality. The GIF-Y0002 provides information on cell abnormality in addition to the features revealed by currently available magnifying endoscopy.

The clinical utility of single-balloon enteroscopy: a single-center experience of 172 procedures.

BACKGROUND: Single-balloon enteroscopy (SBE) is a novel endoscopic technique designed to evaluate and treat small-bowel disease. Although there is substantial literature addressing double-balloon enteroscopy and its impact on the diagnosis and management of small-bowel disease, there are limited data available on the clinical utility of SBE. OBJECTIVES: To evaluate the clinical utility and diagnostic impact of SBE in a large cohort of patients at a single tertiary center. DESIGN: Single-center, retrospective study. SETTING: Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio. PATIENTS: A total of 161 patients were referred for SBE from January 2006 to August 2008. MAIN OUTCOME MEASUREMENTS: Demographic, clinical, procedural, and outcome data were collected and analyzed. RESULTS: A total of 161 patients underwent a total of 172 procedures. Antegrade and retrograde approaches were used in 83% and 17% of subjects, respectively. The average insertion depth using the antegrade approach was 132 cm beyond the ligament of Treitz (range 20-400 cm). The average insertion depth using the retrograde approach was 73 cm above the ileocecal valve (range 10-160 cm). The average procedure time was 40 minutes overall, 38 minutes (range 12-90) antegrade and 48 minutes (range 28-89) retrograde. Fluoroscopy was used in 20 cases (12%). Diagnostic yield was 58% (99/172); 42% (72/172) were therapeutic cases. There were no significant complications. LIMITATIONS: Single-center, retrospective study. CONCLUSIONS: SBE demonstrated a high diagnostic yield and frequently provided useful therapeutic intervention. It seems to be a safe and effective method for performing deep enteroscopy.

Gastric fundic gland polyps: a clinico-pathological study from North West Tasmania.

BACKGROUND: Fundic gland polyps (FGPs) of the stomach were originally described in association with familial polyposis syndromes. It is now known that the majority of these polyps occur in the sporadic setting and are incidentally seen in up to 1.9% of routine upper gastrointestinal endoscopes. The aim of this study was to look at the clinico-pathological features of the FGPs and to analyse their relationship to Helicobacter pylori infection, proton pump inhibitor treatment, colonic polyps and malignancy. METHODS: A search of the histopathology records for a period of 10 years from 1997 to 2006 identified 120 patients with a histologically confirmed diagnosis of FGPs. The clinical history, upper gastrointestinal endoscopy findings, histopathology and colonoscopy findings were recorded from the medical records and analysed. RESULTS: FGPs were seen in 3.2% of patients undergoing routine upper gastrointestinal endoscopes. There was a definite association with long-term proton pump inhibitor treatment. There was a strikingly low incidence of H. pylori infection in the study population. Although there was no dysplasia or malignancy in any of these polyps, one patient had concomitant adenocarcinoma of the stomach. In the subgroup of patients who also had colonoscopy during the study period, 19% had associated colonic polyps and 6% had associated colonic malignancies. CONCLUSIONS: Every new patient diagnosed with FGPs should have a thorough clinico-pathological study to see if the polyps are part of a sporadic or syndromic setting. A long-term follow-up study of patients with FGPs and its association with colonic polyps may be warranted.

Audit of provincial gastroenterology services in the Western Cape.

BACKGROUND: While disorders such as gastro-oesophageal reflux disease, gastrointestinal (GI) cancers and inflammatory bowel disease are prevalent among all racial groups in the Western Cape, there is little knowledge of local GI service provision. The state of equipment, facilities and staffing is largely unrecorded and to date unknown. The aim of this study was to audit the availability of GI facilities in the provincial sector, which provides care for the majority of people in the Western Cape. METHOD: All hospitals in the Western Cape providing endoscopy were evaluated by means of a hands-on audit, to identify available organisational infrastructure. Data including staffing, details and utilisation of existing equipment, maintenance and disinfection techniques and delays in service provision were collected. RESULTS: Over a period of 12 months, 17 Western Cape hospitals were visited: 3 tertiary, 5 regional and 9 district-level institutions. There are currently 89 GI endoscopes in state service, with an average age of 6.1 years (range 1-23 years). While most institutions utilise video endoscopy, in many instances equipment is near the end of its economic life. A total of 26,434 endoscopic procedures were performed over a 12-month period. Overall at least 60% of all adult endoscopy was undertaken at tertiary institutions. The mean delay from consultation until gastroscopy or colonoscopy was 9.25 weeks (range 0.5-28 weeks) and 8 weeks (range 1-20 weeks), respectively. Only 1 tertiary and 1 regional hospital employed fully trained, registered nurses, and the majority of institutions did not conform to internationally accepted standards for the maintenance and disinfection of endoscopic equipment. CONCLUSION: While endoscopy equipment is widely distributed throughout the province, it is evident from this study that services in the Western Cape fall short of international standards, with delays in endoscopic provision, lack of adequate equipment, inadequate scope maintenance and disinfection and a shortage of trained staff. As such, much of the population reliant on state facilities has poor access to GI health care. These deficiencies need to be addressed.

Endoscopic shuffling, infection control, and the clinical practice of push enteroscopy.

Failure to identify and diagnose the site and cause of obscure bleeding or some other gastrointestinal disorder may be an indication for push enteroscopy. During this procedure, a long, narrow, flexible gastrointestinal endoscope, known as a push enteroscope, is advanced into the upper gastrointestinal tract to examine and evaluate the proximal section (first one third) of the small bowel. Because of limited funding and inadequate instrument availability, some gastrointestinal endoscopy units may perform this procedure using a colonoscope instead of a push enteroscope. Although not specifically designed for push enteroscopy, colonoscopes are less expensive than push enteroscopes and readily available for clinical use in virtually every gastrointestinal endoscopy unit. The use of a colonoscope or other lower gastrointestinal endoscope to perform push enteroscopy or another upper gastrointestinal procedure (or the use of an upper gastrointestinal endoscope to perform a lower gastrointestinal procedure) is defined in this article as endoscopic shuffling. Although it is arguably efficient and cost effective (and in some instances may improve clinical outcomes), endoscopic shuffling raises a number of economic, legal, medical, and ethical questions and concerns, several of which are discussed in this article, with a particular focus on infection control.

Flexible versus rigid endoscopy for treatment of foreign body impaction in the esophagus.

BACKGROUND: The use of either flexible endoscopy (FE) or rigid endoscopy (RE) for removal of ingested foreign bodies (FBs) impacted in the esophagus is still discussed controversially. METHODS: We report a consecutive series of 139 patients with FB impaction in the esophagus. During a 6-year period, 69 men and 70 women (median age, 64 [0.7-97] years) requiring removal of an impacted FB underwent either RE (n = 63) in the Otolaryngology Department of our hospital or FE (n = 76) in the Surgical Endoscopy Unit. RESULTS: Foreign body removal was equally effective with FE (success rate 93.4%) and RE (95.2%, p = n.s.). The cases in which foreign body removal failed (5 FE cases [6.6%] and 3 RE cases [4.8%]) were all subsequently successfully managed with "conversion" and use of the other technique. No severe complications occurred when FB removal was attempted with FE (0 of 76 cases; 0.0%), whereas RE was associated with esophageal rupture requiring immediate surgical intervention in 2 of 63 cases (3.2%; p < 0.002). Patient comfort differed significantly between the two procedures (p < 0.0001); RE was always performed under general anesthesia (100.0%), whereas only a minority of patients undergoing FE required general anesthesia (13.0%; p < 0.0001) or mild analgosedation (20.0%). The better patient comfort with FE was also reflected in a significantly lower rate of dysphagia (15%) compared to RE (48%; p < 0.0001). Rigid endoscopy was more frequently used in removal of FBs of the upper esophagus (p < 0.0001), whereas FE was the predominate approach to FBs in the lower esophagus (p < 0.0001). CONCLUSIONS: A tailored approach to treatment of FB impaction is recommended. Because of the lower rate of severe complications, better patient comfort with a lower rate of dysphagia, and lack of requirement for general anesthesia, FE should be the "first line" approach to FBs, although RE has its place as the "second line" therapy.

The yield of wireless capsule endoscopy in the detection of neuroendocrine tumors in comparison with CT enteroclysis.

BACKGROUND: Patients with neuroendocrine tumors (NET) of the small bowel often present with metastatic disease, and localization of the primary tumor still is a diagnostic challenge. Wireless capsule endoscopy (WCE) is an established method that improves the diagnostic evaluation of diseases of the small intestine. OBJECTIVE: The aim of this study was to determine the diagnostic accuracy of WCE in imaging neuroendocrine tumors of the small bowel in these patients. DESIGN: We retrospectively compared the findings of capsule endoscopy to the findings of CT enteroclysis in patients with histopathological confirmation of NET. PATIENTS: Eight patients with newly established diagnosis of metastatic NET were included. INTERVENTIONS: All patients underwent CT enteroclysis and wireless capsule endoscopy within a maximum of 2 weeks. MAIN OUTCOME MEASUREMENTS: Number of primary tumors detected. The results of surgery were used as a gold standard for both methods. RESULTS: CT enteroclysis detected the primary tumor in 4 of 8 patients whereas WCE found the primary in 3 patients. On the contrary, CT enteroclysis provided more false-positive results. LIMITATIONS: Frequent extraluminal tumor growth. CONCLUSIONS: In patients with NET, wireless capsule endoscopy may be helpful in individual cases but the general diagnostic value of this method may be limited due to frequent extraluminal growth of these tumors.

A prospective multicenter clinical and endoscopic follow-up study of patients with gastroesophageal reflux disease.

BACKGROUND: Despite its high prevalence, data on the course of gastroesophageal reflux disease (GERD) are still sparse. There is also an ongoing debate on the natural history of its various manifestations, i.e., non-erosive reflux disease (NERD) vs. erosive reflux disease (ERD) vs. Barrett's esophagus (BE). PATIENTS AND METHODS: This study was conducted within the framework of a prospective multicenter study on the course and prevalence of intestinal metaplasia at the gastroesophageal junction. 1014 dyspeptic patients were screened by the means of upper GI endoscopy. Clinical data were recorded by the use of a questionnaire. At least 15 months after the initial examination, all patients were invited for follow-up (FU) examination. Patients were analyzed separately with respect to their clinical and endoscopic findings. For the latter, only patients without any treatment with proton-pump-inhibitors (PPI) prior to initial and follow-up examinations were included. Patients were categorized as GERD positive if typical symptoms were present and/or proton pump inhibitors were used. RESULTS: Sufficient clinical and/or endoscopic data were available in 590 GERD patients with heartburn at least once a week. Follow-up data could be obtained in 320 patients (clinical FU: n = 304; endoscopic FU: n = 52) after a mean follow-up period of 35 months (18-48 months). 96 of 144 previously asymptomatic patients (67%) remained asymptomatic at follow-up, the rest (n = 48) were symptomatic. 143 of 304 previously symptomatic patients (47%) were symptom-free at follow-up, and only 161 patients (53%) remained symptomatic or had concomitant therapy with proton-pump-inhibitors (PPI). For follow-up endoscopy in patients off PPI (n = 52), ERD was no longer confirmed in 7/12 ERD patients (58%), whereas progress to ERD was found in 3/34 patients (9%) in the NERD group. BE was newly diagnosed in two NERD patients but could no longer be detected in 2 of 6 patients with an initial diagnosis of BE. CONCLUSIONS: With respect to its clinical as well as its endoscopic manifestations, gastroesophageal reflux disease does not appear to be very stable over time. However, in most cases this is due to regression rather than progression of the disease.

[Video capsule endoscopy in a group of networked users: effective and cost saving]. / Videokapselendoskopie im Anwenderverbund: effektiv und kostensparend.

BACKGROUND: At present extensive application of video capsule endoscopy (VCE) as the most innovative diagnostic tool for small bowel diseases is limited by its high costs. The present study describes the first experience in the mobile use of VCE in a cooperation of associated gastroenterology departments in different hospitals. METHODS: The VCE device was bought by a centrally located hospital. In the case of a need for VCE elsewhere the mobile equipment was brought to the respective hospital. The examination was done on site by local physicians, who additionally were responsible for the procedure itself. The evaluation of the VCE pictures was carried out exclusively by the Ophysicians of the central hospital. RESULTS: Within 15 months VCE was performed in 40 patients (19 male, 21 female; age 61 +/- 14 years). Ten examinations were performed in the central hospital, 30 in the associated gastroenterology departments of other hospitals. Indications for VCE were obscure GI bleeding (65 %), chronic diarrhea and Crohn's disease (17.5 %) or suspected small bowel neoplasms (17.5 %). Clinically relevant pathological abnormalities were detected in 62.5 % of the patients, mainly ulcerations and erosions. Complications were non-spontaneous capsule passage in one patient. Compared to a single hospital, the multicenter use of VCE increased the frequency of investigations four times and reduced expenses to almost 30 %. CONCLUSIONS: The mobile use of VCE makes this innovative technique available for every patient while remaining in his local gastroenterology department. Additionally, this concept accelerates amortization and improves the quality of evaluation by focusing experience.

Dear Los Angeles Times: the risk of disease transmission during gastrointestinal endoscopy.

UNLABELLED: This is the second in a series of articles that review media reports investigating the risk of disease transmission associated with gastrointestinal flexible endoscopy. The first article in this series, " COMMENTARY: Do Scopes Spread Sickness?'' was published in this journal in 1999 (Gastroenterology Nursing, 22(4), 179-180).