A88 EVALUATING THE ACCEPTABILITY AND EFFICACY OF CYTOSPONGE FOR BARRETT'S ESOPHAGUS: A SINGLE CENTRE CROSS-SECTIONAL STUDY

Background

Barrett's Esophagus (BE) is a pre-malignant condition defined by the presence of metaplastic columnar epithelial cells above the gastroesophageal junction. Currently, diagnoses is made by endoscopy. Once metaplasia is present, there is 0.5% annual risk of progression to dysplasia and ultimately adenocarcinoma.

Cytosponge is a new device and technique to diagnose BE. Furthermore, this test has a strong safety profile. Research has suggested increased patient tolerance for the Cytosponge compared to endoscopy; this has not been demonstrated in a Canadian healthcare setting. Before Cytosponge test can be integrated in Canada, ideally, patient acceptability of this device should be evaluated.

Purpose

To assess patient acceptability, tolerability and integration of Cytosponge in the diagnosis of Barrett's Esophagus in a Canadian healthcare setting. We also assessed the ease of use and familiarity with Cytosponge.

Method

A single-centre, prospective cross-sectional study was conducted to evaluate the acceptability and comfort of patients undergoing Cytosponge procedure.

Outpatients referred for EGD for Barrett's Esophagus at St. Paul’s Hospital between 03/21-07/22 were included. 36 patients with BE have been enrolled in this project. Acceptability was evaluated through Visual Analogue Scale (VAS), Spielberger State Trait Anxiety Inventory (STAI), and Impact of Events Scale (IOES) on the day of procedure, day 7 post procedure and day 90 post procedure. Data from health care providers administering the Cytosponge were collected using the System Usability Scale (SUS).

One-way ANOVA and Tukey’s Honestly Significant Difference tests were completed to assess score differences between follow up.

Result(s)

A total of 36 patients met the inclusion criteria and consented to participate. Of these patients 81.6% were successful in swallowing Cytosponge, 18.4% were unsucessful. ANOVA test revealed statistically significant difference in VAS scores, F(3, 140) = 12.59, p < 0.0000005. There were significant differences in VAS between Day 0 and Day 7, p=0.0032. This was also seen in VAS between Day 0 vs Day 90, p=0.0017.

There were no statistically significant difference in mean STAI scores between different time points, F(3, 140) = 12.59, p=0.44. ANOVA test also showed statistical difference in IOES scores, F(2, 111) = 8.76, p<0.0005. There was statistical difference between day 0 compared to day 7 and between day 0 and day 90, p=0.0045, and p=0.00045 respectively.

Conclusion(s)

Our results demonstrate that Cytosponge is a well tolerated in a Canadian healthcare setting. Follow up scores of VAS and IOES were lower compared to day 0 suggesting that patients found Cytosponge acceptable. A score of 68 and above is considered to be above average on the SUS which measures usability of Cytosponge. The average SUS score in this sample was 65.3, this may suggest that there is a learning curve for health care providers to become familiar with Cytosponge. There were no complications with Cytosponge in this sample.

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Other

Please indicate your source of funding;

Gastroenterology Institute of Research Institute

Disclosure of Interest

None Declared

A96 IMPROVING AUTOMATED TELEHEALTH SERVICES TO MEET THE NEEDS OF PATIENTS AND HEALTHCARE PROFESSIONALS

Background

There is a growing demand for automated telehealth programs in medicine to improve health-related behaviours such as adherence to treatment schedules. In addition, these services are a promising alternative to increase access to medical care for rural and marginalized patients.

Although promising, telehealth programs need to be evaluated based on patient responsiveness in order to tailor automated services to their target population and identify factors that minimize response rates.

Purpose

To evaluate the effect of socioeconomic, health and structural factors on the response rate of an automated follow-up program implemented at St. Paul’s Hospital in Vancouver, BC.

Method

A retrospective chart review was conducted of patients who did not respond when contacted by a PAtient-Guided Complication Tracking System (PACTS). PACTS sent Short Message Service (SMS) to outpatients having a flexible sigmoidoscopy, gastroscopy and/or colonoscopy one week post-procedure.

Patients who received PACTS SMS between 03/21-08/21 were included in this study. Individuals were considered non-responsive if they failed to reply after receiving an initial SMS and a second reminder text message (sent 24 hours after the first SMS).

Socioeconomic factors including: age, sex and personal annual income were assessed. Income was analyzed using postal code census data. To study health factors, patient comorbidity was evaluated using the Charlson Comorbidity Index (CCI) where CCI > 2 was considered high. Finally, access to a general practitioner (GP) was investigated to study structural factors influencing responsiveness to PACTS.

Result(s)

Of the 200 people studied, 109 of these individuals were male (54%) and 91 were female (46%). The mean age of non-respondents was 60.2 ± 16.4. Postal codes were reported for 144 patients (72%) and the mean annual income of these individuals was $48 928 ± $9710. The mean Charlson Comorbidity Index was 2.1 ± 1.7. 109 non-respondents (54%) had a family doctor listed in their chart and 91 non-respondents (46%) did not.

Conclusion(s)

Based on the age, sex, personal annual income and comorbidity results, socioeconomic and health factors do not impact response rate. The large number of non-respondents without GPs indicate that structural factors influence responsiveness. The high proportion of non-respondents lacking GPs may represent a subgroup of individuals that under-use healthcare services.

Further evaluation of non-respondents and comparative analysis with a large group of respondents are pending and will likely support these conclusions.

Please acknowledge all funding agencies by checking the applicable boxes below

None

Disclosure of Interest

None Declared

A75 AUTOMATED FOLLOW-UP USING A PATIENT-GUIDED COMPLICATION TRACKING SYSTEM (PACTS): AN UPDATE ON PROGRESS

Background

In recent years, there has been an increase in automated interventions in medicine. The COVID-19 outbreak has further fueled this rise. In response to the pandemic, Healthcare systems have developed a multitude of technological strategies for case identification and contact tracing. It is in this evolving digital landscape, that a PAtient-guided Complication Tracking System (PACTS) was launched.

PACTS allows clinics to track complications using the Short Message Service (SMS). This program also offers opportunities to augment medical services and support patients having complications.

Before PACTS can be widely implemented in clinics, research needs to be conducted to investigate its potential as a complication tracking software.

Aims

To assess the outcomes of an automated follow-up program implemented at St. Paul’s Hospital in Vancouver, BC.

Methods

A prospective study was designed to contact outpatients one-week post-procedure using PACTS.

This program was delivered in two phases. Stage 1 ran from November 2019-March 2020. During this pilot stage, patients having a colonoscopy or gastroscopy were asked to participate in the study. Stage 2 ran from August 2020-August 2021. For this phase, patients having a colonoscopy, gastroscopy or flexible sigmoidoscopy were automatically enrolled in the study. An independent t-test was completed to assess response rate differences between stages.

SMS responses were recorded and patients having unplanned events were contacted by phone to categorize complications. Adverse events (AE) were defined as side-effects requiring telehealth follow-up or emergency room visitation. Severe adverse events (SAE) were classified as complications requiring admission to hospital (>24 hrs).

Results

SMS prompts were sent to 6975 patients and the overall mean response rate was 89%. The mean response rates from Stages 1 and 2 were 92% and 88% respectively. The independent t-test revealed a statistically significant difference in response rates between phases, two-sample t(174) = 4.56, p = 9.58 x 10^–6.

498 (8%) of SMS respondents reported having unplanned events. Of these patients, 372 (75%) were reached by phone and 257 (69%) were confirmed to have had a side effect. 65 of these complications were AEs and of these, 3 cases were SAEs. The most common AEs were abdominal pain (37%), bleeding (35%), nausea and vomiting (14%).

Conclusions

The high response rates achieved during this study provide further evidence for the use of automated follow-up systems in medicine. This study also demonstrates the potential of PACTS as a complication tracking software.

Future research should devise strategies to optimize the collection of complication data using an SMS-based service.

Funding Agencies

None, NRC

Comparing the Real-World Effectiveness of High- Versus Low-Volume Split Colonoscopy Preparations: An Experience Through the British Columbia Colon Cancer Screening Program

Background

The British Columbia Colon Screening Program (BCCSP) is a population-based colon cancer screening program. In December 2018, physicians in Vancouver, Canada agreed to switch from a low-volume split preparation to a high-volume polyethylene glycol preparation after a meta-analysis of studies suggested superiority of the higher volume preparation in achieving adequate bowel cleansing and improving adenoma detection rates.

Aims

To compare the quality of bowel preparation and neoplasia detection rates using a high-volume split preparation (HVSP) versus a low-volume split preparation (LVSP) in patients undergoing colonoscopy in the BCCSP.

Methods

A retrospective review of patients undergoing colonoscopy through the BCCSP at St. Paul’s Hospital from July 2017 to November 2018 and December 2018 to November 2019 was conducted. Inclusion criteria included age 50 to 74 and patients undergoing colonoscopy through the BCCSP. Variables collected included patient demographics and bowel preparation quality. Rates of bowel preparation and neoplasia detection were analyzed using chi-squared test.

Results

A total of 1453 colonoscopies were included, 877 in the LVSP group and 576 in the HVSP group. No statistically significant difference was noted between rates of inadequate bowel preparation (LVSP 3.6% versus HVSP 2.8%; P = 0.364). Greater rates of excellent (48.4% versus 40.1%; P = 0.002) and optimal (90.1% versus 86.5%; P = 0.041) bowel preparation were achieved with HVSP. The overall adenoma detection rate was similar between the two groups (LVSP 53.1% versus HVSP 54.0%; P = 0.074). LVSP demonstrated higher overall sessile serrated lesion detection rate (9.5% versus 5.6%; P = 0.007).

Conclusions

Compared to LVSP, HVSP was associated with an increase in excellent and optimal bowel preparations, but without an improvement in overall neoplasia detection.

A88 PATIENT AND PHYSICIAN PERSPECTIVE OF TELE-HEALTH IN GASTROENTEROLOGY

Background

Given the social distancing measures employed to reduce the transmission of SARS-CoV-2, tele-health has rapidly expanded and is now routinely used in new patient encounters and in follow up appointments across Canada.

Aims

To determine the patient and physician perspective towards tele-health in a gastroenterology outpatient setting.

Methods

An anonymous voluntary online survey was distributed to patients who had previously undergone at least one tele-health visit in a tertiary care gastroenterology outpatient setting. A separate online survey was distributed to gastroenterologists practising across Canada.

Results

A total of 181 patients from British Columbia (59.8% female) completed the survey. The tele-health appointment was the first visit for 21.8% of patients. Appointments occurred by phone call alone (61.4%) or by video and audio software (38.6%) and started within 5 minutes of the scheduled time in 75% of visits. Patient satisfaction with the tele-health visit was high (8.54 on a scale of 0–10; 0 completely dissatisfied, 10 extremely satisfied; IQR 8–10). Most patients did not perceive a difference in likelihood of compliance compared to a non-tele-health visit (90.6%), were not concerned about the lack of physical exam during a tele-health visit (82.4%) and did not with-hold information they would have revealed in person (88.7%). After the COVID-19 pandemic, some patients would prefer tele-heath visits (39.2%), whereas others would prefer in office visits (28.5%) and the remainder were indifferent (32.3%). Post-pandemic, most patients would prefer tele-health for follow up visits (68.4%), over tele-health for all possible visits (27.9%) or no tele-health visits (3.8%).

A total of 25 Canadian gastroenterologists (28.0% female; 60% academic practice, 40% community practice) completed a separate survey. Regarding the lack of physical exam in tele-health, 44% of physicians believed this did not affect the quality of their assessment, whereas some physicians believed it had either minimally (48%) or greatly (8%) impaired the quality of their assessment. Almost all physicians (96%) perceived that patients either appreciate tele-health as much as or more than in office visits.

Post-pandemic, most physicians (96%) supported a hybrid model of both tele-health and in office visits. Appointments for follow up of benign endoscopic pathology results (96%), follow up visits (92%), consultations prior to endoscopy (76%) were deemed to be most appropriate for tele-health. Follow up of malignant pathology results (24%) and consultations for new patients (32%) were thought to be less appropriate for tele-health visits.

Conclusions

Patient and physician satisfaction with tele-health in a Canadian outpatient gastroenterology setting is high. Most patients and physicians wish for tele-health to remain available in the post-pandemic setting.

Funding Agencies

Gastrointestinal Research Institute, Vancouver, British Columbia

A164 PATTERNS IN MEDICAL THERAPY AND CLINICAL OUTCOMES IN PATIENTS WITH CONCOMITANT INFLAMMATORY BOWEL DISEASE AND PRIMARY SCLEROSING CHOLANGITIS: A SINGLE CENTRE RETROSPECTIVE ANALYSIS

Background

Inflammatory bowel disease (IBD) in patients with primary sclerosing cholangitis (PSC) is characterized by pancolitis with rectal sparing and is associated with an increased risk of colorectal and biliary malignancies. Currently, pharmacologic management of IBD in the setting of PSC is the same as in IBD alone.

Aims

To assess patterns in medical therapy, and incidence of adverse outcomes in patients with concomitant IBD and PSC.

Methods

A retrospective review was conducted on all PSC-IBD patients followed between January 2010 and June 2018. The Endoscopic Mayo Score was used to grade IBD severity in PSC-ulcerative colitis (UC).

Results

69 patients were identified, 44 (63.8%) were male. The mean ages of IBD and PSC diagnosis were 28.6 (SD 14.9) and 37.0 (SD 18.9) years, respectively. The median length of follow up was 12 (range 2–49) years. 52 (75.4%) patients had UC, and 17 (24.6%) had Crohn’s disease (CD). 28 (87.5%) PSC-UC patients had pancolitis, and 4 (12.5 %) had proctitis. Among those with pancolitis, 8 (28.6%) had relative rectal sparing. 4 (14.3%) patients had more severe inflammation proximally, whereas only 1 (3.6%) had more severe distal inflammation. 23 (82.1%) patients had the same degree of inflammation throughout. 14 (93.3%) PSC-CD patients had colitis/ileocolitis and 1 (6.7%) had ileitis. Among those with PSC-UC, 16 (50.0%), 12 (37.5%), and 4 (12.5%) patients had grade 1, 2, and 3 disease, respectively. 62 (89.9%) PSC-IBD patients were treated with aminosalicylates, and 26 (37.7%) with biologics at some point in their IBD course. 26 (37.7%) were treated with aminosalicylates alone. 4 (5.8%) did not require any IBD therapy. Cholangiocarcinoma, colorectal cancer, and gallbladder cancer developed in 8 (11.6%), 1 (1.4%), and 1 (1.4%) PSC-IBD patients, respectively. 16 (23.2%) patients required partial or total colectomy. Indication for surgery was inflammation or stenosis, dysplasia, and neoplasia in 13 (81.3%), 2 (12.5%), and 1 (6.3%) patients, respectively.

Conclusions

The majority of this cohort had UC with mild disease activity. Pancolitis was common, with frequent rectal sparing and more severe right-sided inflammation. Despite the predominance of low-grade colitis, a large portion of patients required treatment with biologics. The incidence of adverse outcomes underscores the need for strict adherence to recommended surveillance practices. Low grade endoscopic activity, typical of the quiescent IBD course in PSC-IBD, may mask low grade histologic inflammation, which in turn may contribute to the increased risk of colonic neoplasia. Further studies are needed to determine the best management strategy for IBD in patients with PSC.

Funding Agencies

None

A83 IMPACT OF TELEHEALTH ON MEDICATION ADHERENCE IN GASTROENTEROLOGY CHRONIC DISEASE MANAGEMENT

Background

With the COVID-19 pandemic, the demand and availability of telehealth in outpatient care has increased. Although use of telehealth has been studied and validated for various medical specialties, relatively few studies have looked at its role in gastroenterology despite burden of chronic diseases such as inflammatory bowel disease (IBD).

Aims

To assess effectiveness of telehealth medicine in gastroenterology by comparing medication adherence rate for patients seen with telehealth and traditional in-person appointment for various GI conditions.

Methods

Retrospective chart analysis of patients seen in outpatient gastroenterology clinic was performed to identify patients who were given prescription to fill either through telehealth or in-person appointment. By using provincial pharmacy database, we determined the prescription fill rate.

Results

A total of 241 patients were identified who were provided prescriptions during visit with their gastroenterologists. 128 patients were seen through in-person visit during pre-pandemic period. 113 patients were seen through telehealth appointment during COVID pandemic.

The mean age of patients in telehealth cohort was 42 years (57% male). On average patients had 10 prior visits with their gastroenterologists before index appointment, used for adherence assessment. 92% of patients were seen in follow-up, while 8% were seen in initial consultation. The majority of the patients in the telehealth cohort had IBD (89%), while the remaining 11% had various diagnoses, including functional GI disorder, gastroesophageal reflux disease, viral hepatitis, or hepatobiliary disorders. Biologic therapy was the most commonly prescribed medication (66.4%). 45 patients were provided either new medication or dose change, and 68 patients had prescription refill to continue their current medications. It took a mean of 18 days (SD = 16.2) for patients to fill their prescriptions.

Prescription fill rate for patients seen through telehealth and in-person visit were 98.2% and 89.1% (P = 0.004) respectively. Patients seen through telehealth were 6.8 times more likely to fill their prescriptions compared to the in-person counterparts (OR 6.82, CI 1.51 – 30.68, P = 0.004). When we compared adherence rate while excluding biologic therapies, the prescription fill rate was 94.7% in telehealth group and 81.4% in in-person group (OR 4.11, CI 0.88 – 19.27, P = 0.056). Due to high level of adherence, statistical analysis comparing adherent and non-adherent groups was performed but yielded insignificant results.

Conclusions

Medication adherence rate for patients seen through telehealth was higher compared to patients seen through in-patient visit in this study. Telehealth is a viable alternative for outpatient care especially for patients with chronic GI conditions such as IBD.

Funding Agencies

None

A110 PATIENT-GUIDED COMPLICATION TRACKING SYSTEM (PACTS): BUILDING ALLIANCES WITH PATIENTS FOR THE CONTINUED IMPROVEMENT OF POST-PROCEDURAL OUTCOMES

Background

In Healthcare, interventions using Short Message Service (SMS) are growing as more patients have mobile phones. To date, studies have investigated using SMS to remind patients of upcoming appointments and provide preventative medical care. Although SMS interventions exist, little is known about their potential as a post-procedural follow-up tool.

SMS follow-up systems present a unique opportunity for clinics to provide support to patients having unplanned post-procedural events. Moreover, the identification of these cases promotes the adoption of preventative measures. Before SMS follow-up programs can be integrated in clinics, proof-of-concept research needs to be conducted to assess the feasibility of this intervention.

Aims

This study aims to determine intervention design elements to maximize the response rate of a novel follow-up program implemented at St. Paul’s Hospital in Vancouver, BC.

Methods

An iterative prospective study was conducted to assess the effects of various design features on the response rate of an SMS follow-up system.

Outpatients having a colonoscopy and/or gastroscopy at St. Paul’s Hospital between 11/19-03/20 were considered for inclusion in this pilot. Patients were asked to participate if they understood Grade 10-level English and had a mobile phone.

For this pilot, a PAtient-guided Complication Tracking System (PACTS) was designed to send SMS to patients one week post-procedure. During each program round, adjustments were made to PACTS with the goal of increasing the response rate. The design changes made to the pilot were cumulative.

One-way ANOVA and Tukey’s Honestly Significant Difference tests were completed to assess response rate differences between rounds.

Results

A total of 1829 patients met the inclusion criteria and consented to participate in the pilot. The overall median response rate was 93%. ANOVA test revealed a statistically significant difference in response rates between rounds, F(6, 196) = 3.369, p = 0.0035. Only the mean response rates between Rounds 1 and 7 yielded a significant pairwise difference (p &lt; 0.001).

Conclusions

The PACTS pilot demonstrates that high response rates are achievable by SMS follow-up systems. This study identified several design elements to optimize SMS intervention response rates. These features included: sending a 1st SMS that explains the program’s purpose, sending a 2nd SMS to participants that did not respond to the first, and providing pilot information to patients upon admission and discharge.

Future research on SMS follow-up systems should explore designing a program that can be integrated in clinics with minimal staff involvement.

Funding Agencies

None

A149 COMPARING THE REAL-WORLD EFFECTIVENESS OF 4L VERSUS 2L SPLIT COLONOSCOPY PREPARATIONS: PRELIMINARY DATA OF A SINGLE CENTRE EXPERIENCE THROUGH THE BRITISH COLUMBIA COLONOSCOPY SCREENING PROGRAM

Background

The British Columbia Colon Screening Program (CSP) is a population-based program offering biennial fecal immunochemical test (FIT) to individuals age 50–74 years with follow-up colonoscopy for a positive FIT as well as individuals with a personal history of neoplastic polyps or a high risk family history of colorectal cancer. Over 20,000 colonoscopies are performed annually. In December 2018, program colonoscopists in Vancouver, Canada agreed to switch from a 2L polyethylene glycol (PEG) preparation to a 4L PEG preparation after studies suggested superiority of the higher volume preparation in achieving adequate bowel cleansing and improving adenoma detection rates (ADR). High quality bowel cleansing is critical to minimize repeat procedures and maximize neoplasia detection.

Aims

To compare the quality of bowel preparation and neoplasia detection rates using the 4L high volume split preparation (HVSP) versus the 2L low volume split preparation (LVSP) in patients undergoing colonoscopy in the BC CSP.

Methods

A retrospective review of consecutive patients undergoing colonoscopy through the CSP at St. Paul’s Hospital from Dec 2017-Apr 2018 and Dec 2018-Apr 2019 was conducted. Inclusion criteria included: age 50–74, patients undergoing colonoscopy for any reason through the BC CSP. Variables collected included: patient demographics, bowel preparation qualty and pathologic findings. ADR and sessile serrated polyp detection rate (SSDR) were analyzed.

Results

462 colonoscopies were included, 280 in the LVSP group and 182 in the HVSP group. 8/280 (2.9%) had poor bowel preparation in the LVSP group, while 10/182 (5.5%) had poor bowel preparation in the HVSP group. The ADR and SSDR were 53.6% in LVSP vs. 50.0% in HVSP and 8.2% in LVSP vs. 8.8% in HVSP, respectively.

Conclusions

In this preliminary evaluation, the high volume PEG-based split preparation did not reduce the proportion of inadequate bowel preparations. Further evaluation of a larger number of colonoscopies is planned.

Funding Agencies

None

A151 ASSESSMENT OF CAPSULE ENDOSCOPY UTILIZING CAPSOCAM PLUS® IN PATIENTS WITH SUSPECTED SMALL BOWEL DISEASE INCLUDING PILOT STUDY WITH REMOTE ACCESS PATIENTS

Background

Capsule endoscopy (CE) has been widely utilized for the assessment of patients with known/suspected small bowel disease. The CapsoCam Plus® capsule is unique in that it utilizes four cameras at sequential 90 degree intervals in its mid-section permitting a 360-degree panoramic perspective with a 15+ hour battery life. A panoramic view has been suggested to improve overall visualization of the small bowel (SB) therefore potentially improving diagnostic yield. Unlike other small bowel capsules, it must be retrieved upon excretion (utilizing a magnetic kit) since the images are stored on the device.

Aims

To assess the use of CapsoCam Plus in patients referred for suspected small bowel disease, including pilot assessments for patients in remote locations.

Methods

A retrospective chart review (01/16 – 09/19) assessing consecutive capsule procedures utilizing this device was performed. Information acquired included basic demographics, indication, extent of examination, gastric transit time, small bowel transit time, yield, adverse events, capsule retention, recovery rates and recommendations for follow up. A pilot study was also initiated for patients in rural centers to access capsule testing remotely through mail courier without attendance/travel to the primary dispensing site.

Results

Acquired data included 63 patients receiving CapsoCam Plus®. Indications: 32% obscure gastrointestinal bleeding, 52% iron deficiency anemia, 2% abdominal pain and 6% for IBD. 92% of studies were completed to cecal visualization. Mean gastric and small bowel transit time were 0:48:17 and 3:54:29. 94% were retrieved using retrieval kits provided to patients. 2% retrieved endoscopically from the stomach (retained due to pyloric stenosis), 2% retained in terminal ileum (previously undiagnosed stricture) and 2% not retrieved due to failure of patient to use retrieval kit. 73% of studies were normal SB, 13% contained SB ulceration/erosive disease and 8% did not demonstrate the entire small bowel. Recommendations for follow up included supportive therapy (47%), more aggressive iron supplementation (1%), repeat capsules (19%) and 14% for routine office follow up and discussion. All three capsules mailed to patients in remote communities were completed successfully.

Conclusions

CapsoCam Plus® had a high retrieval rate of 97% demonstrating that with appropriate patient selection, recovery rates are very high. Only 3% of patients had retained capsules. Most patients in this study had a normal small bowel, however; images and completion rates were adequate to assess small bowel in the vast majority of patients. Success was obtained with mailing this capsule to remote sites sparing the patient travel to the dispensing site.

Funding Agencies

None

A137 COLONOSCOPY RELATED ADVERSE EVENTS IN A POPULATION-BASED COLON SCREENING PROGRAM

Background

The British Columbia Colon Screening Program (BCCSP) is a population-based program enrolling 50–74 year old individuals for biennial FIT (OC-Sensor, cut-off 10 mcg/g) with follow-up colonoscopy for positive FIT. The neoplasia detection rate is 50–55% and over 75% of colonoscopies have a specimen taken. Previously reported colonoscopy adverse event rates for FIT based screening programs vary widely: 0.03–6.2% and 0–2.7% for bleeding and perforation, respectively. Mortality as a result of colonoscopy is rare but has been reported in 0.0004%-0.0074% of colonoscopies. The rate of colonoscopy related adverse events in BCCSP participants is unknown.

Aims

To determine the rate of colonoscopy related serious adverse events within the BCCSP.

Methods

This is a retrospective cohort study of all participants undergoing colonoscopy in BCCSP from November 15, 2013 to December 31, 2017. BCCSP contacts screening participants by phone 14 days post colonoscopy to determine unplanned medical visits the day prior (during bowel preparation) or following the colonoscopy. Unplanned events underwent chart review if the event was a perforation, cardiovascular or respiratory event, or resulted in death, hospitalization, or significant intervention including repeat colonoscopy, interventional radiology, surgery, blood transfusion, cardioversion, casting of a fracture or suturing of a laceration. Chart review was conducted by a Colonoscopy Lead and reviewed by BCCSP Quality Committee. Unplanned events were defined as serious adverse events (SAE) if they resulted in death, hospitalization or significant intervention and further classified as probably, possibly, or unlikely related to the colonoscopy.

Results

A total of 108,004 colonoscopies were performed. Unplanned events were reported in 1753 participants, of which 586 met criteria for review. Of these, 578 were confirmed unplanned events and 409 were SAEs of which 367 (89.7%) were probably, 22 (5.4%) possibly and 20 (4.9%) unlikely associated with colonoscopy. 36/10,000 colonoscopies were associated with a SAE that was probably or possibly related: perforation in 5/10,000, bleeding 22/10,000. Three deaths occurred in the 14 days following colonoscopy that were probably (2 perforations) or possibly related to the colonoscopy (0.3/10,000).

Conclusions

The BCCSP has a colonoscopy SAE rate in keeping with previous publications, particularly in the context of a very high proportion of procedures associated with polypectomy, a known risk factor for perforation and bleeding. This study will help inform screening participants about the risks of colonoscopy in the BC program. Future studies are required to confirm these rates using hospital admission data.

Funding Agencies

None

A168 IS ROUTINE SCREENING FOR HEREDITARY COLORECTAL CANCER FEASIBLE IN AN OUTPATIENT GASTROENTEROLOGY PRACTICE?

Background

Lynch syndrome (LS) is the most common cause of hereditary colorectal cancer (CRC), with a reported prevalence of 2–5% of all CRC cases. A study by Kastrinos et al. found that a simple 3 item survey identified 77% of individuals at high risk for hereditary CRC. Implementation of this questionnaire at a gastroenterology office may help identify patients at risk for LS and other hereditary CRC.

Aims

To assess whether implementation of a validated questionnaire to screen for hereditary CRC is feasible in an outpatient gastroenterology clinic.

Methods

Adult gastroenterology outpatients who consented to participate in the study completed the screening questionnaire. Those who had previously been assessed by the Hereditary Cancer Program were excluded. Each subject was asked the following three questions: (1) Do you have a first-degree relative with CRC or LS-related cancer diagnosed before age 50? (2) Have you had CRC or polyps diagnosed before age 50? (3) Do you have ≥3 relatives with CRC?. Answering yes to any question was considered a positive screen.

Results

A total of 288 patients were screened, with 12 (4.2%) screening positive for question 1, 28 (9.7%) screening positive for question 2, and 8 (2.8%) screening positive for question 3. In total, 14.2% of individuals surveyed screened positive.

Conclusions

Utilization of a simple 3-question survey as part of regular patient intake in a gastroenterology office resulted in 14.2% of individuals screening high-risk for hereditary CRC. This is similar to the 15% screen positive rate in the original study of individuals with CRC. Further research is needed to determine whether a physician’s knowledge of the questionnaire results will change management and whether a positive screen leads to a confirmed diagnosis of LS and other hereditary colorectal cancers.

Funding Agencies

None

A165 ASSESSING ATTENDANCE OF SUBSTANCE USER ENDOSCOPIES (A.S.U.R.E)

Background

In Canada, British Columbia (BC) is the leading province in opioid deaths with 30.6 per 100,000 population. Since substance users are stigmatized in health care, patient care requires specific, individualized management strategies, which often creates a gap between the patient and health care service. Diagnostic studies remain a challenge due to lack of funding and the unique requirements necessary to treat this patient population efficiently. Thus, new methods of prevention must be cultivated to ensure ideal patient care.

Aims

To investigate the proportion of patients on restricted narcotics that failed to attend scheduled gastroenterology and hepatology appointments at our center.

Methods

A retrospective chart review from 01/05 – 07/19 and data analysis of patients (≥ 19 yrs.) referred to a Downtown Gastroenterology office was performed. Data was collected from an electronic medical record system and filtered through a keyword search for ‘Methadone’, ‘Suboxone’, ‘Dilaudid’, and ‘Morphine’ to create a sample size of patients with recent/ongoing use of narcotic agents. Patients with chronic pain, or terminal illness prescribed these drugs were not included. Demographic information, type of appointment scheduled and failure to attend were recorded.

Results

Acquired data yielded 2630 patients of which 350 patient were included. Mean age was 47 years (61% male). 35% of the patients were current narcotics users, the rest being previous users of these agents. Scheduled appointments and non-attendance are shown in Tables 2 and 3. Most patients (70%) were referred for various general GI complaints with HCV accounting for 23% of the consults. Despite the use of confirmation lines, 20% of HCV referred patients and 29% of non-HCV referred patients did not attend their first appointment.

Conclusions

Current and prior narcotic users failed to attend more than one quarter of scheduled gastroenterology/hepatology appointments. Ideal management of care for GI disease can’t be obtained without contact with those that provide the service. Creative, innovative management strategies are required to ensure ideal care for this unique group of patients.

Funding Agencies

None

A272 THE CANADIAN DIRECT OBSERVATION OF PROCEDURAL SKILLS (CANDOPS) TOOL FOR ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY: A MULTI-CENTRE PROSPECTIVE STUDY

Background

Previous studies have demonstrated that many graduating trainees may not have all of the skills needed to independently practice endoscopic retrograde cholangiopancreatography (ERCP) safely and effectively. As a part of competency-based learning curriculum development, it is essential to provide formative feedback to trainees and ensure they acquire the knowledge and skills for independent practice.

Aims

To assess the performance of advanced endoscopy trainees across Canada using the Canadian Direct Observation of Procedural Skills (CanDOPS) ERCP assessment tool. Procedural items evaluated include both technical (cannulation, sphincterotomy, stone extraction, tissue sampling, and stent placement) and non-technical (leadership, communication and teamwork, judgment and decision making) skills.

Methods

We conducted a prospective national multi-centre prospective study. Advanced endoscopy trainees with at least two years of gastroenterology training or five years of general surgery in North America and minimal experience performing ERCPs (less than 100 ERCP procedures) were invited to participate. The CanDOPS tool was used to measure every fifth ERCP performed by trainees over a 12-month fellowship training period. ERCPs were evaluated by experienced staff endoscopists at each study site under standard clinical protocol. Cumulative sum (CUSUM) analyses were used to generate learning curves.

Results

The data from five Canadian sites and 11 trainees participated in the study. A total of 261ERCP evaluations were completed. Median number of evaluations by site and trainee was 49 (IQR 31–76) and 15 (IQR 11–45). Median number of cases trainees performed prior to their ERCP training was 50 (IQR 25–400). There was a significant improvement in almost all scores over time, including selective cannulation, sphincterotomy, biliary stenting and all non-technical skills (P&lt;0.01). CUSUM analyses using acceptable and unacceptable failure rates of 20% and 50% demonstrated trainees achieved competency for most measures in their final month of their training. Competency in tissue sampling was not achieved within a one-year training period.

Conclusions

This is the first ERCP performance evaluation tool that examines multiple technical and non-technical aspects of the procedure. Although trainee ERCP skills do improve during their training period, there exists a notable variability in time to competency for the different skills measured using the CanDOPS tool. Large prospective research is required to determine if competency is achieved using more stringent definitions of ERCP competency and to determine factors associated with reaching competency.

Funding Agencies

None

A154 ASSESSING COLON SCREENING PROGRAM COLONOSCOPIES IN A NON-HOSPITAL ENDOSCOPY CLINIC

Background

Colorectal cancer is the most commonly diagnosed cancer in British Columbia, affecting 1 in 6 persons. The BC Colon Screening Program (CSP) screens individuals 50–74 years of age with biennial FIT (cut-off 10 mcg/g) with follow-up colonoscopy for positive results. In Vancouver, colonoscopies are performed in a hospital environment; however non-hospital endoscopy clinics have been used in other jurisdictions.

Aims

To investigate the quality of procedure, rate of complications and need to repeat procedures in a hospital setting for colonoscopies performed on CSP patients in a non-hospital setting.

Methods

A retrospective chart review for all CSP colonoscopies performed from 04/19 to 07/19 in a non-hospital endoscopy clinic. Data was collected from an electronic medical record system and included adenoma detection rates; any repeat procedures required in a hospital setting and adverse event rates. Criteria for a repeat in hospital colonoscopy were inadequate bowel preparation, body mass index exceeding the allowable threshold for a non-hospital colonoscopy and identification of a difficult to remove polyp such as a polyp &gt; 20 mm or in a difficult location.

Results

801 FIT positive patients (ages 50–74) underwent colonoscopy in the non-hospital endoscopy clinic. The mean age was 60 years (51% female). The mean time between referral date and procedure date was 192 days. The neoplasia detection rate was 60.2%, there was one (0.1%) adverse event (post-polypectomy bleed) and 21 (2.6%) patients required a repeat colonoscopy in a hospital setting.

Conclusions

Colonoscopy to follow-up a positive FIT in an non-hospital endoscopy clinic was safe and effective with a low number of repeat, in hospital colonoscopies required.

Funding Agencies

None

A163 MICROCOSTING: ASSESSING HEALTH ECONOMICS IN GI

Background

Micro-costing is a method of collecting precise cost measurements and proves effective in determining economic requirements needed to support health interventions. At St. Paul’s GI Clinic, over 12000 procedures are performed yearly, 80% of which are colonoscopies. Specific standards in the form of appropriate documentation are recommended through Global Rating Scale (GRS) and require yearly auditing to ensure appropriate compliance with these standards. These audits require a time commitment of staff to assess charts. The cost of performing these assessments is not known.

Aims

To determine the cost of annual data collection suggested by GRS for documentation of procedures.

Methods

A retrospective chart review and data analysis of patients (≥ 19 years old) admitted to St. Paul’s GI Clinic for a colonoscopy and/or esophagogastroduodenoscopy (EGD). Data is extracted from the St. Paul’s medical database from August 1st 2018 – August 1st 2019. Since it is a ‘time-and-motion’ study, a stopwatch is used to time the collection of data from each chart. The mean time per-case is derived and used to conduct an appropriate economic analysis, such as total working hours, per-minute salary calculations and equipment costs. The purpose is to determine a yearly cost and identify what the main cost drivers were (time/labor).

Results

As per our annual review format suggested by GRS, 260 procedure reports were reviewed, 150 colonoscopies and 110 EGDs (random sampling of 10 per physician for each type of procedure). A spread sheet outlining key data assessment points for mandatory standard reporting points has been used yearly and was used for this study as well. Mean evaluation time (including recording presence or absence of each item on our standard reporting form): 1 minute and 40 seconds to review the report for a colonoscopy and 1 minute and 33 seconds to review the report for an EGD. A total of 2 hours 51 minutes 16 seconds to review all the EGD reports and 4 hours 8 minutes and 46 seconds for the colonoscopy reports.

Conclusions

It would cost $126 annually to pay a research student, who makes $18/ hour, to collect this quality assurance data required for auditing completeness of physician colonoscopy and EGD procedure documentation according to standards.

Funding Agencies

None

Internet-Based Patient Education Prior to Colonoscopy: Prospective, Observational Study of a Single Center’s Implementation, with Objective Assessment of Bowel Preparation Quality and Patient Satisfaction

Background

Nonpharmacologic factors, including patient education, affect bowel preparation for colonoscopy. Optimal cleansing increases quality and reduces repeat procedures. This study prospectively analyzes use of an individualized online patient education module in place of traditional patient education.

Aims

To determine the effectiveness of online education for patients, measured by the proportion achieving sufficient bowel preparation. Secondary measures include assessment of patient satisfaction.

Methods

Prospective, single-center, observational study. Adults aged 19 years and over, with an e-mail account, scheduled for nonurgent colonoscopy, with English proficiency (or someone who could translate for them) were recruited. Demographics and objective bowel preparation quality were collected. Patient satisfaction was assessed via survey to assess clarity and usefulness of the module.

Results

Nine hundred consecutive patients completed the study. 84.6% of patients achieved adequate bowel preparation as measured by Boston bowel preparation score ≥ 6 and 90.1% scored adequately using Ottawa bowel preparation score ≤7. 94.2% and 92.1% of patients rated the web-education module as ‘very useful’ and ‘very clear’, respectively (≥8/10 on respective scales).

Conclusions

Our analysis suggests that internet-based patient education prior to colonoscopy is a viable option and achieves adequate bowel preparation. Preparation quality is comparable to previously published trials. Included patients found the process clear and useful. Pragmatic benefits of a web-based protocol such as time and cost savings were not formally assessed but may contribute to greater satisfaction for endoscopists and patients.

Benefit of Capsule Endoscopy in the Setting of Iron Deficiency Anemia in Patients Above Age 65

Background

Iron deficiency anemia (IDA) is a common indication for a capsule endoscopy (CE), which is often offered after a negative bidirectional endoscopy. Since malignancy is a concern in the older population with IDA, upper and lower endoscopic exams are typically performed. If these tests are negative, CE may be offered to evaluate the small intestine. However, choosing the ideal candidates who are most likely to benefit from a CE study is challenging.

Aims

The goal of this study was to assess the outcomes for CE in patients with IDA over age 65 and assess which factors are more likely to contribute to a positive CE yield.

Methods

A retrospective review of all CE studies at St. Paul's Hospital from January 2010 to June 2016 was conducted after ethics approval. Inclusion criteria included the following: age >65, hemoglobin <120 g/L, serum ferritin <70 μg/L, and at least one high-quality complete EGD/colonoscopy performed before CE. Variables to assess factors that are more likely to contribute to a positive capsule yield included use of anticoagulation medications, NSAIDs, PPIs, transfusion burden and cardiac disease. A Chi-Square test was then used to determine clinical predictive factors of a positive and negative study.

Results

There were 1149 CE studies that were reviewed, of which 130 CE studies met inclusion criteria. Fifty-one studies (40.6%) had positive findings, and from this group, 30 (58.8%) recommended active intervention (i.e., EGD, n = 8; colonoscopy, n = 12; push enteroscopy, n = 3; double-balloon [DB] enteroscopy, n = 2; small bowel resection, n = 3; escalation of Crohn's therapy, n = 2), while 21 (41.2%) were managed supportively, typically with iron supplementation. Most negative studies (73 of 79) recommended supportive therapy (other recommendations included hematological workup, n = 3; hiatal hernia repair, n = 1; proton-pump inhibitors [PPI] initiation, n = 1; stop donating blood, n = 1).A history of cardiac disease had a significant association with positive findings (0.54 versus 0.33, P = 0.001). Conversely, a known history of low ferritin levels (0.84 versus 0.68, P = 0.046) and a known history of hiatal hernia (0.25 versus 0.08, P = 0.012) were associated with a negative study.

Conclusions

These findings suggest that the clinical yield of CE in IDA in patients above age 65 is relatively low. The majority of all CE studies recommended supportive therapy or repeat endoscopic exams (EGD/colonoscopy) of areas previously assessed and lesions missed. Provided that initial endoscopic exams were thorough and Crohn's disease management was optimized, the overall rate of changing management significantly was low at five of 130 studies (two DB enteroscopies and three resections) or 3.8%. Clinical factors focusing on cardiac history, ferritin levels and the presence of a hiatal hernia may be of utility to predict benefit of CE. Emphasis on these data may help select more appropriate patients for capsule endoscopy.

ACG and CAG Clinical Guideline: Management of Dyspepsia

We have updated both the American College of Gastroenterology (ACG) and the Canadian Association of Gastroenterology (CAG) guidelines on dyspepsia in a joint ACG/CAG dyspepsia guideline. We suggest that patients ≥60 years of age presenting with dyspepsia are investigated with upper gastrointestinal endoscopy to exclude organic pathology. This is a conditional recommendation and patients at higher risk of malignancy (such as spending their childhood in a high risk gastric cancer country or having a positive family history) could be offered an endoscopy at a younger age. Alarm features should not automatically precipitate endoscopy in younger patients but this should be considered on a case-by-case basis. We recommend patients <60 years of age have a non-invasive test Helicobacter pylori and treatment if positive. Those that are negative or do not respond to this approach should be given a trial of proton pump inhibitor (PPI) therapy. If these are ineffective tricyclic antidepressants (TCA) or prokinetic therapies can be tried. Patients that have an endoscopy where no pathology is found are defined as having functional dyspepsia (FD). H. pylori eradication should be offered in these patients if they are infected. We recommend PPI, TCA and prokinetic therapy (in that order) in those that fail therapy or are H. pylori negative. We do not recommend routine upper gastrointestinal (GI) motility testing but it may be useful in selected patients.

Clinical Practice Guidelines for the Use of Video Capsule Endoscopy

BACKGROUND & AIMS

Video capsule endoscopy (CE) provides a noninvasive option to assess the small intestine, but its use with respect to endoscopic procedures and cross-sectional imaging varies widely. The aim of this consensus was to provide guidance on the appropriate use of CE in clinical practice.

METHODS

A systematic literature search identified studies on the use of CE in patients with Crohn's disease, celiac disease, gastrointestinal bleeding, and anemia. The quality of evidence and strength of recommendations were rated using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

The consensus includes 21 statements focused on the use of small-bowel CE and colon capsule endoscopy. CE was recommended for patients with suspected, known, or relapsed Crohn's disease when ileocolonoscopy and imaging studies were negative if it was imperative to know whether active Crohn's disease was present in the small bowel. It was not recommended in patients with chronic abdominal pain or diarrhea, in whom there was no evidence of abnormal biomarkers typically associated with Crohn's disease. CE was recommended to assess patients with celiac disease who have unexplained symptoms despite appropriate treatment, but not to make the diagnosis. In patients with overt gastrointestinal bleeding, and negative findings on esophagogastroduodenoscopy and colonoscopy, CE should be performed as soon as possible. CE was recommended only in selected patients with unexplained, mild, chronic iron-deficiency anemia. CE was suggested for surveillance in patients with polyposis syndromes or other small-bowel cancers, who required small-bowel studies. Colon capsule endoscopy should not be substituted routinely for colonoscopy. Patients should be made aware of the potential risks of CE including a failed procedure, capsule retention, or a missed lesion. Finally, standardized criteria for training and reporting in CE should be defined.

CONCLUSIONS

CE generally should be considered a complementary test in patients with gastrointestinal bleeding, Crohn's disease, or celiac disease, who have had negative or inconclusive endoscopic or imaging studies.

Diagnosis and Management of Barrett's Esophagus: A Retrospective Study Comparing the Endoscopic Assessment of Early Esophageal Lesions in the Community versus a Specialized Center

Specialized endoscopic evaluation for patients with Barrett's esophagus (BE) is well supported; however, no studies have shown that centers with expertise provide better quality care for BE with high-grade dysplasia or early adenocarcinoma. In this study, the investigators aimed to evaluate the management and clinical course for patients treated in a community practice versus a specialized BE center. Methods. A retrospective analysis of referrals from the community to our specialized center for evaluation of BE at St Paul's Hospital Division of Gastroenterology between January 2007 and February 2014 was performed. Subjects were patients who were referred for BE and dysplasia and subsequently reevaluated by endoscopy. The pathology and endoscopy reports from the community and our center were reviewed. Inclusion criteria were as follows: being ≥ 19 years old and pathologic diagnosis of BE or dysplasia in the community. Exclusion criteria were as follows: incomplete pathology data or incomplete endoscopy reports from the community physicians. Results. A total of 77 patients were reviewed. The staging of 28.9% of patients referred from the community was changed from the initial pathological diagnosis. 18.4% of these patients were upstaged. Using Fischer's exact test, we showed that, in our specialized center, endoscopic impressions correlated significantly with pathology results (p < 0.0001).

Methotrexate in combination with infliximab is no more effective than infliximab alone in patients with Crohn's disease

BACKGROUND & AIMS

Methotrexate and infliximab are effective therapies for Crohn's disease (CD). In the combination of maintenance methotrexate-infliximab trial, we evaluated the potential superiority of combination therapy over infliximab alone.

METHODS

In a 50-week, double-blind, placebo-controlled trial, we compared methotrexate and infliximab with infliximab alone in 126 patients with CD who had initiated prednisone induction therapy (15-40 mg/day) within the preceding 6 weeks. Patients were assigned randomly to groups given methotrexate at an initial weekly dose of 10 mg, escalating to 25 mg/week (n = 63), or placebo (n = 63). Both groups received infliximab (5 mg/kg of body weight) at weeks 1, 3, 7, and 14, and every 8 weeks thereafter. Prednisone was tapered, beginning at week 1, and discontinued no later than week 14. The primary outcome was time to treatment failure, defined as a lack of prednisone-free remission (CD Activity Index, <150) at week 14 or failure to maintain remission through week 50.

RESULTS

Patients' baseline characteristics were similar between groups. By week 50, the actuarial rate of treatment failure was 30.6% in the combination therapy group compared with 29.8% in the infliximab monotherapy group (P = .63; hazard ratio, 1.16; 95% confidence interval, 0.62-2.17). Prespecified subgroup analyses failed to show a benefit in patients with short disease duration or an increased level of C-reactive protein. No clinically meaningful differences were observed in secondary outcomes. Combination therapy was well tolerated.

CONCLUSIONS

The combination of infliximab and methotrexate, although safe, was no more effective than infliximab alone in patients with CD receiving treatment with prednisone. ClincialTrials.gov number, NCT00132899.

The cost-effectiveness of screening for colorectal cancer

BACKGROUND

Published decision analyses show that screening for colorectal cancer is cost-effective. However, because of the number of tests available, the optimal screening strategy in Canada is unknown. We estimated the incremental cost-effectiveness of 10 strategies for colorectal cancer screening, as well as no screening, incorporating quality of life, noncompliance and data on the costs and benefits of chemotherapy.

METHODS

We used a probabilistic Markov model to estimate the costs and quality-adjusted life expectancy of 50-year-old average-risk Canadians without screening and with screening by each test. We populated the model with data from the published literature. We calculated costs from the perspective of a third-party payer, with inflation to 2007 Canadian dollars.

RESULTS

Of the 10 strategies considered, we focused on three tests currently being used for population screening in some Canadian provinces: low-sensitivity guaiac fecal occult blood test, performed annually; fecal immunochemical test, performed annually; and colonoscopy, performed every 10 years. These strategies reduced the incidence of colorectal cancer by 44%, 65% and 81%, and mortality by 55%, 74% and 83%, respectively, compared with no screening. These strategies generated incremental cost-effectiveness ratios of $9159, $611 and $6133 per quality-adjusted life year, respectively. The findings were robust to probabilistic sensitivity analysis. Colonoscopy every 10 years yielded the greatest net health benefit.

INTERPRETATION

Screening for colorectal cancer is cost-effective over conventional levels of willingness to pay. Annual high-sensitivity fecal occult blood testing, such as a fecal immunochemical test, or colonoscopy every 10 years offer the best value for the money in Canada.

Endoscopic missed rates of upper gastrointestinal cancers: parallels with colonoscopy

Recent publications assessing colonoscopy missed rates of colorectal cancer have generated efforts toward colonoscopy quality improvement. To date, esophagogastroduodenoscopy (EGD) has escaped similar scrutiny in Western populations. Raftopoulos et al. (1) report an upper gastrointestinal cancer missed rate of up to 6.7% in a cohort of 28,000 patients who underwent EGD at a hospital-based endoscopy unit in Perth, Western Australia. Of the missed esophageal and gastric cancers, approximately 80% of patients had alarm symptoms and 73% had abnormalities reported at the time of EGD. The missed cancers may not have been visualized, or were visualized and either not biopsied or biopsied inadequately, or interpreted incorrectly by pathologists. There was no difference in survival between the missed cancers and those detected at the index EGD.

Gastrointestinal manifestations of systemic mastocytosis

Systemic mastocytosis (SM) is a rare disease with abnormal proliferation and infiltration of mast cells in the skin, bone marrow, and viscera including the mucosal surfaces of the digestive tract. Gastrointestinal (GI) symptoms occur in 14%-85% of patients with systemic mastocytosis. The GI symptoms may be as frequent as the better known pruritus, urticaria pigmentosa, and flushing. In fact most recent studies show that the GI symptoms are especially important clinically due to the severity and chronicity of the effects that they produce. GI symptoms may include abdominal pain, diarrhea, nausea, vomiting, and bloating. A case of predominantly GI systemic mastocytosis with unique endoscopic images and pathologic confirmation is herein presented, as well as a current review of the GI manifestations of this disease including endoscopic appearances. Issues such as treatment and prognosis will not be discussed for the purposes of this paper.

Electronic endoscopic information systems: what is out there?

This review summarizes some of the endoscopy electronic medical records (EEMRs) that are presently available. The objective is simply to familiarize the reader with some of the important systems and key features. It is not meant to be exhaustive, as a complete review of EEMRs would involve much more than a simple article; this document simply provides an introduction from which the groundwork can be laid.