Procedure volume influences adherence to celiac disease guidelines.

BACKGROUND: Although the prevalence of celiac disease in the USA approaches 1%, most cases are undiagnosed, in part, because of low adherence to the recommendation of submitting at least four specimens during duodenal biopsy. We aimed to determine whether physician and practice characteristics are associated with adherence to this recommendation. MATERIALS AND METHODS: We used a large national pathology database to identify all adult patients who underwent duodenal biopsy during 2006-2009. Hierarchical modeling was used to determine whether procedure volume, the number of gastroenterologists per endoscopy suite, and the number of gastroenterologists per capita of the zip code of the practice were associated with adherence. RESULTS: We identified 92 580 patients (67% female, mean age 53.5 years) who met our inclusion/exclusion criteria. Specimens were submitted by 669 gastroenterologists from 200 endoscopy suites, located in 191 zip codes, with a mean of 3.4 gastroenterologists per suite. On multivariate analysis, a higher procedure volume was associated with a decreased adherence [odds ratio (OR) for each additional 100 procedures, 0.92; 95% confidence interval (CI), 0.88-0.97; P=0.002]. An increased adherence was reported for gastroenterologists working at suites with higher numbers of gastroenterologists (OR for each additional gastroenterologist, 1.08; 95% CI, 1.04-1.13; P<0.001) but not for a higher gastroenterologist density in the zip code of the practice (OR for each additional gastroenterologist per capita, 1.01; 95% CI, 0.99-1.03; P=0.21). CONCLUSION: High-volume physicians exhibit lower rates of adherence to biopsy guidelines, possibly because of the additional time required to submit at least four specimens. In contrast, a greater number of endoscopists working in an endoscopy suite are associated with an increased adherence, possibly because of peer education.

Lymphocytic oesophagitis: clinicopathological aspects of an emerging condition.

OBJECTIVE: Lymphocytic oesophagitis (LyE) has been reported in small series, but no consistent clinical correlations have emerged. The authors sought to determine the prevalence of LyE in a large population and define demographic, endoscopic and clinical findings associated with this condition. DESIGN: In a pilot study, the authors established and disseminated criteria for the histopathological diagnosis of LyE to a group of gastrointestinal pathologists. Eighteen months later the authors reviewed cases with this diagnosis, collected demographic, clinical and endoscopic data, and compared them with patients with either eosinophilic oesophagitis (EoE) or normal oesophageal biopsies. The authors also determined the density of oesophageal lymphocytes in normal controls and in adults with established Crohn's disease. RESULTS: There were 129,252 unique PATIENTS: 40,665 had normal mucosa (median age 55 years; 32% men); 3745 had EoE (median age 43 years; 66% men). A diagnosis of LyE was made in 119 patients (median age 63 years, 40% men). Dysphagia was as common in these patients as in those with EoE (53% vs 63%; ns); gastro-oesophageal reflux disease -the most common complaint in patients with normal biopsies (37%)-was low in both the LyE and the EoE groups (18% vs 19%, ns). EoE was suspected in one-third of the patients. CONCLUSION: LyE was detected in ∼0.1% of patients with oesophageal biopsies. The clinical and endoscopic characteristics of LyE and EoE overlap considerably; however, LyE affects predominantly older women. Although the precise clinical significance of oesophageal lymphocytic infiltrates remain to be defined, their association with dysphagia and possibly motility disorders warrants further investigations.

No association between gastric fundic gland polyps and gastrointestinal neoplasia in a study of over 100,000 patients.

BACKGROUND & AIMS: Fundic gland polyps (FGPs), the most common type of gastric polyps, have been associated with prolonged proton pump inhibitor therapy and an increased risk of colon cancer. The presence of FGPs has been inversely correlated with Helicobacter pylori infection. We evaluated the prevalence of H pylori-associated gastritis, colonic polyps, and carcinomas in subjects with and without FGPs. METHODS: We analyzed data collected from community-based endoscopy centers in 36 states (plus Washington DC and Puerto Rico) on patients who underwent esophagogastroduodenoscopy (EGD) and colonoscopy between April 2007 and March 2008. Of the 103,385 patients who underwent EGD during this time period, gastric biopsy samples were collected from 78,801 and colonic biopsies from 26,017. Slides of samples from Helicobacter-infected FGPs and FGPs with dysplasia were reviewed. RESULTS: FGPs were detected in 6081 patients (67.8% women). Helicobacter infection was present in less than 0.5% patients with FGPs and 13.0% of those without FGPs (odds ratio [OR], 29.05; 95% confidence interval [CI], 20.4-41.4; P < .0001). Colonic adenomas were detected in 42.3% of women with FGPs and 33.8% of those without (OR, 1.43; 95% CI, 1.26-1.63; P < .001); there was no significant difference in colonic adenomas between men with and without FGPs. CONCLUSIONS: Women had a higher prevalence of FGPs. FGPs were associated with gastroesophageal reflux disease symptoms, gastric heterotopia, hyperplastic colonic polyps (only in men), and colonic adenomas (only in women, especially those over 60 years of age). The presence of FGPs was inversely correlated with H pylori infection, active gastritis, and gastric neoplasia.