Targeted housestaff intervention reduces opioid use without worsening patient-reported pain scores and improves outcomes among patients with IBD: the "IBD pain ladder".

BACKGROUND AND AIMS: Opioid analgesic use is associated with increased mortality, higher readmission rates, and reduced quality of life among patients with inflammatory bowel disease (IBD). With the goal of reducing inpatient opioid use among patients with IBD admitted to our inpatient gastroenterology (GI) service, we designed and implemented a standardized, educational intervention providing analgesic decision support to internal medicine and emergency medicine housestaff at our institution. METHODS: Pre-intervention data was collected from patients admitted during a 9-month period prior to intervention. Post-intervention patients were identified prospectively. The primary outcome was reduction in aggregate inpatient opioid use in oral morphine equivalents per patient. RESULTS: A total of 68 patients with 81 hospitalizations were analyzed. There was no statistically significant difference in baseline admission characteristics between the two groups. Our primary outcome was achieved with a statistically significant reduction in opioid use during hospitalization (43.4 mg vs 7.7 mg; p < 0.01). Secondary outcomes achieved included reduction in new opioid prescriptions upon discharge, reduced hospital length of stay, and reduced 90-day readmission rates. There was no significant difference between patients' pain scores between the two groups. CONCLUSION: We believe this intervention, aimed at housestaff education, provides a roadmap for pain management decision-making in this patient population. It is a readily reproducible strategy that can be widely applied to improve inpatient IBD patient care. Importantly, patient experience and pain scores were unchanged despite lower use of inpatient opioid analgesia, highlighting successful opioid-sparing analgesics in most inpatients with IBD.

An endoscopic training and assessment model for argon plasma coagulation.

PURPOSE: Argon plasma coagulation (APC) is a standard modality for the treatment of gastrointestinal bleeding. However, there are no metrics to assess technical proficiency. We aimed to determine if a Quick APC Training Test (QAPCTT) can improve performance and assess proficiency with this modality. MATERIALS AND METHODS: Endoscopy trainees at various levels of training were asked to perform the QAPCTT with an in vivo model before and after an APC curriculum with didactic lectures and additional hands-on experience. As trainees performed the test, endoscopic supervisors recorded the time required to complete each task as well as the number of inadvertent mucosal touchdowns. Each partipant was assigned a technical proficiency score by supervising endoscopists. RESULTS: Fourteen adult gastroenterology fellows participated in the course. 100% of fellows were comfortable with generator settings and APC equipment after the course compared to only 21% (p < 0.001) on the pre-test questionnaire. Those deemed technically proficient on the post-course QAPCTT required significantly less time for the task of making a square (100 s vs. 215 s; p = 0.006) and had significantly fewer inadvertent mucosal touchdowns (5 vs. 19; p = 0.0017). CONCLUSIONS: Dedicated APC training is required to achieve competence with this modality. A structured curriculum improves knowledge about the technique and hands-on training is important for achieving technical proficiency. The QAPCTT appears improve APC technique and may readily identify trainees in need of additional APC experience to gain proficiency.

Migration of a Lumen-Apposing Metal Stent into the Colon.

The introduction of lumen-apposing metal stents (LAMS) has been an important development in the management of pancreatic fluid collections. Stent migration out of pancreatic fluid collections into the stomach has been reported, despite the special anti-migratory design of the bi-flanged stent. Data on stent migration rates remain sparse, with some studies suggesting a migration rate of 3.3-5%. There have been no reported cases of LAMS migration outside of the stomach. We describe the first reported case of a transgastric LAMS migrating from the stomach and passing into the colon.

A rare case of Crohn's ileitis in a patient with constitutional mismatch repair deficiency.

Constitutional mismatch repair deficiency (CMMRD), a variant of Lynch syndrome, is a rare disease characterized by café-au-lait spots, oligopolyposis, glioblastoma and lymphoma. A 24-year-old male, under surveillance for CMMRD, developed Crohn's ileitis after total colectomy with end ileostomy for colorectal cancer and failed to respond to oral corticosteroids. The patient underwent induction and maintenance of remission with vedolizumab infusions. We report the first patient with CMMRD developing Crohn's disease. The choice of immunosuppressive therapy in these patients is challenging and needs to be made according to their risk for malignancy.

Initial experience with a novel EUS-guided core biopsy needle (SharkCore): results of a large North American multicenter study.

BACKGROUND AND AIMS: The ability to safely and effectively obtain sufficient tissue for pathologic evaluation by using endoscopic ultrasound (EUS) guidance remains a challenge. Novel designs in EUS needles may provide for improved ability to obtain such core biopsies. The aim of this study was to evaluate the diagnostic yield of core biopsy specimens obtained using a novel EUS needle specifically designed to obtain core biopsies. PATIENTS AND METHODS: Multicenter retrospective review of all EUS-guided fine-needle biopsies obtained using a novel biopsy needle (SharkCore FNB needle, Medtronic, Dublin, Ireland). Data regarding patient demographics, lesion type/location, technical parameters, and diagnostic yield was obtained. RESULTS: A total of 250 lesions were biopsied in 226 patients (Median age 66 years; 113 (50 %) male). Median size of all lesions (mm): 26 (2 - 150). Overall, a cytologic diagnosis was rendered in 81 % specimens with a median number of 3 passes. When rapid onsite cytologic evaluation (ROSE) was used, cytologic diagnostic yield was 126/149 (85 %) with a median number of 3 passes; without ROSE, cytologic diagnostic yield was 31/45 (69 %, P = 0.03) with a median number of 3 passes. Overall, a pathologic diagnosis was rendered in 130/147 (88 %) specimens with a median number of 2 passes. Pathologic diagnostic yield for specific lesion types: pancreas 70/81 (86 %), subepithelial lesion 13/15 (87 %), lymph node 26/28 (93 %). Ten patients (10/226, 4 %) experienced adverse events: 4 acute pancreatitis, 5 pain, 1 fever/cholangitis. CONCLUSIONS: Initial experience with a novel EUS core biopsy needle demonstrates excellent pathologic diagnostic yield with a minimum number of passes.

A Systematic Review Assessing Medical Treatment for Rectovaginal and Enterovesical Fistulae in Crohn's Disease.

BACKGROUND: Rectovaginal and enterovesical fistulae are difficult to treat in patients with Crohn's disease. Currently, there is no consensus regarding their appropriate management. AIM OF THE STUDY: The aim of the study was to review the literature on the medical management of rectovaginal and enterovesical fistulae in Crohn's disease and to assess their response to treatment. METHOD: A literature search of MEDLINE, EMBASE, Science Citation Index Expanded, and Cochrane was performed. RESULTS: Twenty-three studies were identified, reporting on 137 rectovaginal and 44 enterovesical fistulae. The overall response rates of rectovaginal fistulae to medical therapy were: 38.3% complete response (fistula closure), 22.3% partial response, and 39.4% no response. For enterovesical fistulae the response rates to medical therapy were: 65.9% complete response, 20.5% partial response, and 13.6% no response. Specifically, response to anti-tumor necrosis factor therapy of 78 rectovaginal fistulae was: 41.0% complete response, 21.8% partial response, and 37.2% no response. Response of 14 enterovesical fistulae to anti-tumor necrosis factor therapy was: 57.1% complete response, 35.7% partial response, and 7.1% no response. The response to a combination of medical and surgical therapy in 43 rectovaginal fistulae was: 44.2% complete response, 20.9% partial response, and 34.9% no response. CONCLUSIONS: Medical therapy, alone or in combination with surgery, appears to benefit some patients with rectovaginal or enterovesical fistula. However, given the small size and low quality of the published studies, it is still difficult to draw conclusions regarding treatment. Larger, better quality studies are required to assess response to medical treatment and evaluate indications for surgery.

Sendai and Fukuoka Consensus Guidelines Identify Advanced Neoplasia in Patients With Suspected Mucinous Cystic Neoplasms of the Pancreas.

BACKGROUND & AIMS: Little is known about whether the 2006 Sendai guidelines or 2012 Fukuoka guidelines are being used to determine the level of risk posed by suspected pancreatic mucinous cystic neoplasms (PCNs). We evaluated whether the guidelines accurately predicted which patients with suspected PCNs, which was based on cross-sectional imaging findings, would be found to have advanced neoplasia in surgery. METHODS: We performed a retrospective study of data collected from 194 patients with cystic lesions of the pancreas, which were assessed by cross-sectional imaging analyses, who underwent surgery for suspected PCNs at the Hospital at the University of Pennsylvania from 2000 through 2008. Imaging data were used to classify patients according to the Sendai guidelines as high risk or low risk and according to the Fukuoka guidelines as high risk, worrisome, or low risk. Pathology analyses of samples collected during surgery were used as the reference. A logistic regression model was created to identify factors associated with advanced neoplasia. The Sendai and Fukuoka guideline criteria were analyzed by univariate and multivariable logistic regression analyses. RESULTS: Advanced neoplasias were found in 36 patients (18.5%; 22 invasive cancers and 14 high-grade dysplasias). The median size of cysts was 33 mm. All patients found to have invasive cancers were accurately assigned to the Sendai guidelines high risk or Fukuoka guidelines high risk groups. However, 3 patients in the Sendai guidelines low risk and 2 patients in the Fukuoka guidelines low risk groups were found to have high-grade dysplasia. The Sendai guidelines identified patients with advanced neoplasia with 91.7% sensitivity, 21.5% specificity, 21% positive predictive value, and 91.9% negative predictive value. A designation of Fukuoka guidelines high risk identified patients with advanced neoplasia with 55.6% sensitivity, 73% specificity, 32% positive predictive value, and 87.9% negative predictive value. Overall, there was no statistically significant difference between the guidelines in predicting which patients had advanced neoplasia. On multivariate analysis, the presence of a mural nodule (odds ratio [OR], 2.88; 95% confidence interval [CI], 1.33-6.27; P = .008), dilated main pancreatic duct >10 mm (OR, 7.44; 95% CI, 2.36-23.52; P = .001), or enhancing solid component (OR, 2.92; 95% CI, 1.16-7.64; P = .02) were associated with detection of advanced neoplasia in pancreatic cysts. CONCLUSION: On the basis of a retrospective analysis, the Sendai and Fukuoka guidelines accurately determine which patients with pancreatic cysts have advanced neoplasia. The guidelines accurately recommended surgical resection for all patients found to have invasive cancer, although some patients with high-grade dysplasia were missed. The updated Fukuoka guidelines are not superior to the Sendai guidelines in identifying neoplasias. Cyst size was not associated with advanced neoplasia.

Radiofrequency ablation for Barrett's esophagus.

PURPOSE OF REVIEW: Several studies published in the last year that have provided evidence on the efficacy, durability and safety of radiofrequency ablation (RFA) in Barrett's esophagus are highlighted in this review. RECENT FINDINGS: RFA is well tolerated and efficacious in most but not all Barrett's esophagus patients with dysplasia and esophageal adenocarcinoma (EAC). Recent reports have described highly variable rates of disease recurrence. Disease progression may occur during initial therapy or after complete eradication in a small, difficult to identify subset of patients. Studies are underway to help determine the predictors of response and recurrence. Modifications in technique and target populations have been described in the last year as well. SUMMARY: Endoscopic mucosal resection and RFA are the cornerstones in the management of dysplasia and early EAC in Barrett's esophagus patients today. Despite the encouraging data on the effectiveness and safety of RFA, recurrence and progression of disease remain an issue in a subset of patients who are treated.

Endoscopic mucosal resection and endoscopic submucosal dissection of epithelial neoplasia of the colon.

Endoscopic mucosal resection (EMR) with curative intent has evolved into a safe and effective technique and is currently the gold standard for management of large colonic epithelial neoplasms. Piecemeal EMR is associated with a high risk of local recurrence requiring vigilant surveillance and repeat interventions. Endoscopic submucosal dissection (ESD) was introduced in Japan for the management of early gastric cancer, and has recently been described for en bloc resection of colonic lesions greater than 20 mm. En bloc resection allows accurate histological assessment of the depth of invasion, minimizes the risk of local recurrence and helps determine additional therapy. Morphologic classification of lesions prior to resection allows prediction of depth of invasion and risk of nodal metastasis, allowing selection of the appropriate intervention. This review provides an overview of the assessment of epithelial neoplasms of the colon and the application of EMR and ESD techniques in their management.