Gastroenterologist focus of clinical practice affects adenoma detection in screening colonoscopy

Our objective was to determine whether the clinical focus of gastroenterology practice would affect screening colonoscopy quality metrics, specifically adenoma detection (AD). In a retrospective study of screening colonoscopies, gastroenterologists were categorized based on their clinical subspecialty focus into general/motility, hepatology, inflammatory bowel disease (IBD), and interventional endoscopy. The primary outcome was AD with a secondary outcome of adenoma and/or sessile serrated polyp (SSP) detection (AD + SSP). A total of 5271 (male: 49.1%) complete colonoscopies were performed between 2010 and 2020 by 16 gastroenterologists (male: 62.5%, general/motility specialists: 3, hepatologists: 3, IBD specialists: 4, interventional endoscopists: 6). The AD and AD + SSP rate between each specialty focus were 27.5% and 31.0% for general/motility, 31.4% and 35.5% for hepatology, 38.4% and 43.6% for IBD, and 37.5% and 43.2% for interventional endoscopy. In regression analysis, patient's male gender (odds ratios [OR]: 1.81, 95% CI: 1.60-2.05, P < .001), longer withdrawal time (OR: 1.16, 95% CI: 1.14-1.18, P < .001), hepatologist (OR: 1.25, 95% CI: 1.02-1.53, P = .029), IBD subspecialist (OR: 1.60, 95% CI: 1.30-1.98, P < .001), and interventional endoscopist (OR: 1.36, 95% CI: 1.13-1.64, P < .001) were independently associated with AD. Moreover, patient's male gender (OR: 1.64, 95% CI: 1.45-1.85, P < .001), acceptable bowel preparation (OR: 1.29, 95% CI: 1.06-1.56, P = .010), withdrawal time (1.20, 95% CI: 1.18-1.22, P < .001), hepatologist (OR: 1.30, 95% CI: 1.07-1.59, P = .008), IBD subspecialist (OR: 1.72, 95% CI: 1.39-2.12, P < .001), interventional endoscopist (OR: 1.44, 95% CI: 1.20-1.72, P < .001) were independent factors that improved detection of AD + SSP. Subspecialty focus of practice was an important factor in AD rate along with the male gender of the patient, bowel preparation, and withdrawal time.

Crystal-Associated Colitis with Ulceration Leading to Hematochezia and Abdominal Pain

Lower GI bleeding is a common cause for hospitalization in adults. Medication-associated mucosal injury is an important clinical entity that can result in significant morbidity and mortality. We present the case of a 45-year-old woman with a 3-month history of intermittent abdominal cramping and rectal bleeding. Her medical history was extensive and included end-stage renal disease and a remote history of endometrial carcinoma that was treated with radiation. Initial workup was concerning for ischemic and radiation colitis, however, histology was most consistent with acute inflammation and ulceration associated with crystal fragments. Sevelamer and cholestyramine are commonly used ion-exchange resins that have been associated with mucosal damage. Both medications were discontinued and her symptoms resolved. Our case highlights an underrecognized but important cause of hematochezia.

Is alcohol required for effective pancreatic cyst ablation? The prospective randomized CHARM trial pilot study

BACKGROUND AND STUDY AIMS

In this study, we aim to determine the safety and feasibility of an alcohol-free approach to pancreatic cyst ablation using a chemotherapeutic ablation cocktail.

PATIENTS AND METHODS

In this prospective, randomized, double-blinded pilot study, 10 patients with known mucinous type pancreatic cysts underwent endoscopic ultrasound (EUS)-guided fine needle aspiration and then lavage with either 80 % ethanol or normal saline. Both groups were then treated with a cocktail of paclitaxel and gemcitabine. Primary outcomes were reduction in cyst volume and rates of complications.

RESULTS

At 6 months, patients randomized to the alcohol arm had an 89 % average volume reduction, with a 91 % reduction noted in the alcohol-free arm. Complete ablation was achieved in 67 % of patients in the alcohol-free arm at both 6 and 12 months, whereas the alcohol group recorded complete ablation rates of 50 % and 75 % at 6 and 12 months, respectively. One patient in the alcohol arm developed acute pancreatitis (20 %) with no adverse events in the alcohol-free arm.

CONCLUSIONS

This study revealed similar ablation rates between the alcohol ablation group and the alcohol-free arm and demonstrates the safety and feasibility of an alcohol-free ablation protocol. This pilot study suggests that alcohol may not be required for effective cyst ablation.

Percutaneous debridement and washout of walled-off abdominal abscess and necrosis using flexible endoscopy: a large single-center experience

BACKGROUND AND STUDY AIMS

Direct percutaneous endoscopic necrosectomy has been described as a minimally invasive intervention for the debridement of walled-off pancreatic necrosis (WOPN). In this retrospective cohort study, we aimed to confirm these findings in a US referral center and evaluate the clinical value of this modality in the treatment of pancreatic necrosis as well as other types of intra-abdominal fluid collections and necrosis.

PATIENTS AND METHODS

Twelve consecutive patients with WOPN or other abdominal abscess requiring debridement and washout underwent computed tomography (CT)-guided drainage catheter placement. Each patient then underwent direct percutaneous endoscopic necrosectomy and washout with repeat debridement performed until complete. Drains were then removed once output fell below 30 mL/day and imaging confirmed resolution. The primary endpoints were time to clinical resolution and sustained resolution at 1-year follow up. 

RESULTS

Ten patients were treated for WOPN, one for necrotic hepatic abscesses, and one for omental necrosis. The median time to intervention was 85 days with an average of 2.3 necrosectomies performed. Complete removal of drains was accomplished in 11 patients (92 %). The median time to resolution was 57 days. No serious adverse events occurred; however, one patient developed pancreaticocutaneous fistulas. Ten patients completed 1-year surveillance of which none required drain replacement. No patients required surgery or repeat endoscopy.

CONCLUSIONS

This series supports the premise that direct percutaneous endoscopic necrosectomy is a safe and effective intervention for intra-abdominal fluid collections and necrosis in appropriately selected patients. Our study demonstrates a high clinical success rate with minimal adverse events. This modality offers several potential advantages over surgical and transgastric approaches including use of improved accessibility, an excellent safety profile, and requirement for only deep or moderate sedation.

Recent advances in the management of difficult constipation

Constipation is a highly prevalent disorder. Some patients suffer from acute, intermittent episodes of constipation. Others, however, suffer from chronic constipation, a term that refers to those patients with symptoms of constipation for more than 6 months. In clinical practice, chronic constipation is often used interchangeably with the term functional constipation, which is currently defined using the Rome III criteria. Symptoms can be burdensome, leading to a reduction in patients' quality of life. In addition, chronic constipation is important because it imposes a significant economic impact to the health care system. Some patients with chronic constipation have persistent symptoms despite implementing lifestyle changes and using either over-the-counter agents or prescription medications. These patients may be categorized as having difficult constipation. This report will focus on recent advances in the management of difficult constipation, and include a discussion of new and upcoming medications as well as new diagnostic tests and procedures.

Immobilization techniques and dosimetric aspects for pituitary tumors

Twelve percent of all intracranial tumors arise in the pituitary fossa. The management of pituitary tumors is a complex process that may combine several treatment modalities including radiation therapy. Minimizing patient movement during the course of radiation therapy treatment is imperative to ensure both the delivery of the prescribed dose to the small target volume and to minimize the radiation dose to critical structures. Several alternative types of immobilization devices are being used for this purpose; these include biteblocks, thermal plastics, and polyurethane molds (Alpha Cradle). The advantages and disadvantages of each of these devices are reviewed and the fabrication process of the pituitary immobilization mold that we are currently using is described. Dosimetric aspects of the treatments using these devices is addressed.