Dyspepsia: A stepwise approach to evaluation and management.

Let a patient's age and specific symptoms steer your initial investigation. Consider treatment options beyond antibiotics for H pylori gastritis and PPIs.

Withdrawal times and associated factors in colonoscopy: a quality assurance multicenter assessment.

OBJECTIVE: To evaluate the use and impact of the recommended withdrawal time of at least 6 minutes from the cecum in colonoscopy in multiple gastroenterology endoscopy ambulatory surgery centers serving a wide geographical area. METHODS: An observational prospective multicenter quality assurance review was conducted in 49 ambulatory surgery centers in 17 states with 315 gastroenterologists. There was no intervention with this quality assessment program as care of patients and the routine of gastroenterologists continued as standard practice. Multivariable analysis was applied to the database to examine factors affecting withdrawal time and polyp detection. RESULTS: There were 15,955 consecutive qualified patients receiving colonoscopies in a designated 4-week period. Gastroenterologists with average withdrawal times of 6 minutes or more in patients with no polyps were 1.8 times more likely to detect 1 or more polyps and had a significantly higher rate (P<0.0001) of polyp detection in patients with findings of polyps compared to gastroenterologists with average withdrawal times of less than 6 minutes in patients with no polyps. For patients with no pathology, the mean time of withdrawal was 6.98 (SD=4.34) minutes and for patients with pathology mean time of withdrawal was 11.27 (SD=6.71) minutes. Strongest predictors of withdrawal time of 6 minutes or more were presence of carcinoma (3.7 times more likely than those with no pathology), adenoma (2.0 times more likely than those with no pathology), and number of polyps visualized (1.7 times more likely for each polyp). CONCLUSIONS: This quality assurance assessment from standard colonoscopy practices of 315 gastroenterologists in 49 endoscopic ambulatory surgery centers serving a wide geographical area provides support for the merits of a colonoscopy withdrawal time from the cecum of 6 minutes or more to improve the detection of polyps.

Evaluating screening age for colonoscopy: a quality assurance assessment.

OBJECTIVE: To evaluate colonoscopies in patients aged 40 to 49 and 50 to 59 years from multiple endoscopy surgery centers serving a wide geographical area. METHODS: An observational prospective multicenter quality assurance review was conducted in 49 Ambulatory Surgery Centers in 17 states with 315 gastroenterologists. Care of patients and routine of gastroenterologists continued as standard practice with patients attending for purposes of screening, surveillance, and symptoms. RESULTS: There were 1688 and 5090 consecutive qualified patients aged 40 to 49 and 50 to 59 years, respectively, receiving colonoscopies in a designated 4 week period. There was no significant difference (P=0.55) in the screening category between ages 40 to 49 (n=420) and 50 to 59 years (n=2705) in incidence of colon polyps although the older age group had more than 6 times the number of patients than the younger age group. Age group of 40 to 49-year-old males (21.5%) are at similar risk to 40 to 49-year-old females (21.1%) in development of carcinoma and adenoma polyps combined. Age group of 50 to 59-year-old males (31.3%) appear at greater risk (P<0.0001) than age 50 to 59-year-old females (18.4%) in development of carcinoma and adenoma polyps combined in the screening category. For surveillance and symptom categories significant differences (P<0.05) occurred between both age groups 40 to 49 and 50 to 59 years for males but not females in development of carcinoma and adenoma polyps combined. CONCLUSIONS: The equal risk of colon polyps in screening colonoscopies for age 40 to 49 and 50 to 59 years suggest reexamination of current recommendations for 50 years as the beginning age for screening colonoscopy. Further studies are needed to examine sex differences and cost effectiveness of screening colonoscopies beginning at age 40 years and to explore these factors as well in surveillance and symptom categories.

Gastrointestinal endoscopy in pregnant and lactating women: emerging standard of care to guide decision-making.

Endoscopic procedures generally are considered to be low-risk modalities, being performed on an on-demand basis in many ambulatory endoscopy centers and hospitals. However, the safety and efficacy of gastrointestinal endoscopy in pregnancy has not been well studied. In pregnancy, the risks to the fetus and mother are numerous and the magnitude of this risk will differ depending on trimester, the disease process being addressed, the underlying health and status of the maternofetal unit, and the nature of the endoscopic intervention being contemplated. Given the difficulties in performing prospective studies in the pregnant patient, these risks have not been well-quantified. Decision-making in practice is at times highly individualized. The obstetrician and endoscopist may therefore need to rely on prudent practice based on personal experience in conjunction with recognized underlying basic principles and consensus guidelines, rather than hard scientific data, to guide decision-making and advising patients. The purpose of this review is to make those caring for pregnant patients aware of the clinical considerations necessary to ensure a successful outcome and to provide guidance with respect to what is now considered to be the standard of care when managing pregnant and lactating patients in whom an endoscopic procedure is being contemplated.