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Beran A, Al-Abboodi Y, Majzoub AM, Ghazaleh S, Sayeh W, Mohamed MFH, Elfert K, Mhanna M, Montalvan-Sanchez E, Musallam R, Jaber F, Bhatti U, Abdeljawad K, Al-Haddad M. Endoscopic Versus Conservative Therapy for Bleeding Peptic Ulcer with Adherent Clot: A Comprehensive Systematic Review and Meta-Analysis. Dig Dis Sci 2023; 68:3921-3934. [PMID: 37634184 DOI: 10.1007/s10620-023-08078-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 08/04/2023] [Indexed: 08/29/2023]
Abstract
INTRODUCTION Peptic ulcers with adherent clots are associated with a high-risk of rebleeding and mortality. However, the optimal management of bleeding ulcers with adherent clots remains unclear. We conducted this systematic review and meta-analysis to compare endoscopic therapy and conservative therapy to manage bleeding ulcers with adherent clots. METHODS We systematically searched PubMed, Embase, and Web of Science databases through October 2022 to include all studies comparing the endoscopic and conservative therapeutic approaches for bleeding ulcers with adherent clots. Our primary outcome was rebleeding (overall and 30-day). The secondary outcomes were mortality (overall and 30-day), need for surgery, and length of hospital stay (LOS). The random-effects model was used to calculate the pooled odds ratios (OR) and mean differences (MD) with the corresponding confidence intervals (CI) for proportional and continuous variables, respectively. RESULTS Eleven studies (9 RCTs) with 833 patients (431 received endoscopic therapy vs. 402 received conservative therapy) were included. Overall, endoscopic therapy was associated with lower overall rebleeding (OR 0.41, 95% CI 0.22-0.79, P = 0.007), 30-day rebleeding (OR 0.43, 95% CI 0.21-0.89, P = 0.002), overall mortality (OR 0.47, 95% CI 0.23-0.95, P = 0.04), 30-day mortality (OR 0.43, 95% CI 0.21-0.89, P = 0.002), need for surgery (OR 0.44, 95% CI 0.21-0.95, P = 0.04), and LOS (MD - 3.17 days, 95% CI - 4.14, - 2.19, P < 0.00001). However, subgroup analysis of randomized controlled trials (RCTs) showed no significant difference in overall mortality (OR 0.78, 95% CI 0.24-2.52, P = 0.68) between the two strategies, with numerically lower but statistically non-significant rates of overall rebleeding (7.2% vs. 18.5%, respectively; OR 0.42, 95% CI 0.17-1.05, P = 0.06), statistically lower rate of need for surgery (OR 0.28, 95% CI 0.08-0.96, P = 0.04) with endoscopic therapy compared to conservative therapy. CONCLUSIONS Our meta-analysis demonstrates that endoscopic therapy was overall associated with lower rates of rebleeding (overall and 30-day), mortality (overall and 30-day), need for surgery, and LOS, compared to conservative therapy for the management of bleeding ulcers with adherent clots. However, subgroup analysis of RCTs showed that endoscopic therapy was associated with numerically lower but statistically non-significant rates of overall rebleeding and a statistically lower rate of need for surgery compared to conservative therapy with similar overall mortality rates. Combined treatment with thermal therapy and injection therapy was the most effective treatment modality in reducing rebleeding risk. Further large-scale RCTs are needed to validate our findings.
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Affiliation(s)
- Azizullah Beran
- Divison of Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, Ste 225, Indianapolis, IN, 46202, USA.
| | - Yasir Al-Abboodi
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA
| | - Abdul Mounaem Majzoub
- Divison of Gastroenterology and Hepatology, University of Missouri, Columbia, MO, USA
| | - Sami Ghazaleh
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA
| | - Wasef Sayeh
- Department of Medicine, University of Toledo, Toledo, OH, USA
| | - Mouhand F H Mohamed
- Department of Medicine, Warren Alpert Medical School Brown University, Providence, RI, USA
| | - Khaled Elfert
- Department of Medicine, St. Barnabas Hospital Health System, Bronx, NY, USA
| | - Mohammed Mhanna
- Division of Cardiology, University of Iowa, Iowa City, IA, USA
| | | | - Rami Musallam
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Fouad Jaber
- Department of Medicine, University of MO - Kansas City, Kansas City, MO, USA
| | - Umer Bhatti
- Divison of Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, Ste 225, Indianapolis, IN, 46202, USA
| | - Khaled Abdeljawad
- Divison of Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, Ste 225, Indianapolis, IN, 46202, USA
| | - Mohammad Al-Haddad
- Divison of Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, Ste 225, Indianapolis, IN, 46202, USA
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Bhatti U, Jansson-Knodell C, Saito A, Han A, Krajicek E, Han Y, Imperiale TF, Fayad N. Not FIT for Use: Fecal Immunochemical Testing in the Inpatient and Emergency Settings. Am J Med 2022; 135:76-81. [PMID: 34508698 DOI: 10.1016/j.amjmed.2021.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 08/01/2021] [Accepted: 08/12/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Fecal immunochemical testing (FIT) is widely used for colorectal cancer screening, its only indication. Its effect on clinical decision-making beyond screening is unknown. We studied the use of FIT in emergency and inpatient settings and its impact on patient care. METHODS Using electronic medical records, we reviewed all non-ambulatory FITs performed from November 2017 to October 2019 at a tertiary care community hospital. We collected data on demographics, indications, gastroenterology consultations, and endoscopic procedures. Multivariate logistic regression was performed to determine the effect of FIT on gastroenterology consultation and endoscopy. RESULTS We identified 550 patients with at least 1 FIT test. Only 3 FITs (0.5%) were performed for colorectal cancer screening. FITs were primarily ordered from the emergency department (45.3%) or inpatient hospital floor (42.2%). Anemia (44.0%), followed by gastrointestinal bleeding (40.9%), were the most common indications. FIT was positive in 253 patients (46.0%), and gastroenterology consultation was obtained for 47.4% (n = 120), compared with 14.5% (n = 43) of the 297 FIT-negative patients (odds ratio 3.28; 95% confidence interval, 2.23-4.82, P < .0001). A potential bleeding source was identified in 80% of patients with reported or witnessed overt gastrointestinal bleeding, a similar proportion (80.7%; P = .92) to patients who were FIT positive with overt gastrointestinal bleeding. Multivariate analysis showed that melena, hematemesis, and a positive FIT were associated with gastroenterology consultation (all P < .05), while only melena (odds ratio 3.34; 95% confidence interval, 1.48-7.54) was associated with endoscopy. CONCLUSIONS Nearly all emergency department and inpatient FIT use was inappropriate. FIT resulted in more gastroenterology consultation but was not independently associated with inpatient endoscopy.
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Affiliation(s)
- Umer Bhatti
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis
| | - Claire Jansson-Knodell
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis
| | - Akira Saito
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis
| | - Andrew Han
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis
| | - Edward Krajicek
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis
| | - Yan Han
- Division of Biostatistics & Health Data Science, Indiana University-Purdue University, Indianapolis
| | - Thomas F Imperiale
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis; Division of Gastroenterology and Hepatology, Department of Medicine, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Ind; Regenstrief Institute, Inc. Indianapolis, Ind
| | - Nabil Fayad
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis; Division of Gastroenterology and Hepatology, Department of Medicine, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Ind.
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Koehn C, Rex DK, Allen J, Bhatti U, Bhavsar-Burke I, Thoguluva Chandrasekar V, Challa A, Duvvuri A, Dakhoul L, Ha J, Hamade N, Hicks SB, Jansson-Knodell C, Krajicek E, Das Kundumadam S, Nutalapati V, Phatharacharukul PP, Razmdjou S, Saito A, Sarkis F, Sutton R, Wehbeh A, Sharma P, Desai M. Optical diagnosis of colorectal polyps using novel blue light imaging classification among trainee endoscopists. Dig Endosc 2022; 34:191-197. [PMID: 34053136 DOI: 10.1111/den.14050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/22/2021] [Accepted: 05/26/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Blue light imaging (BLI) has been shown to improve the characterization of colorectal polyps among the endoscopy experts. We aimed to determine if this technology could be taught to endoscopy trainees while maintaining high accuracy and interobserver agreement. METHODS Twenty-one gastroenterology trainees (fellows) from two academic institutions participated in this prospective study. Each trainee completed a web-based learning comprising four modules: pre-test, didactic videos explaining the BLI Adenoma Serrated International Classification (BASIC), interactive examples, and post-test assessment. The pre- and post-test modules consisted of reviewing video images of colon polyps in high definition white light imaging and BLI and then applying the BASIC classification to determine if the polyps were likely to be adenomatous. Confidence in adenoma identification (rated '1' to '5'), accuracy in polyp (adenoma vs. non-adenoma) identification, and agreement in characterization per BASIC criteria were derived. RESULTS Trainee accuracy in the adenoma diagnosis improved from 74.7% (pre-test) to 85.4% (post-test) (P < 0.01). There was a trend towards higher accuracy in polyp characterization with subsequent years of training (1st year fellows 77.4%, 2nd year 88.5%, and final year 94.0%) with consistent improvements after the e-learning across years of trainees. Overall, trainees were able to identify adenoma with a high sensitivity of 86.9%, specificity 83.9%, positive predictive value of 84.4%, and negative predictive value of 86.5%. However, their interobserver agreement in adenoma diagnosis was moderate (k = 0.52). CONCLUSION The novel BLI classification can be easily taught to gastroenterology trainees using an online module and accuracy improves with years of training reaching >90% for colorectal polyp characterization.
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Affiliation(s)
- Christopher Koehn
- Division of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Douglas K Rex
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, IN, USA
| | - Jimmy Allen
- Division of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Umer Bhatti
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, IN, USA
| | - Indira Bhavsar-Burke
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, IN, USA
| | | | - Abhishek Challa
- Division of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Abhiram Duvvuri
- Division of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Lara Dakhoul
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, IN, USA
| | - John Ha
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, IN, USA
| | - Nour Hamade
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, IN, USA
| | - S Bradley Hicks
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, IN, USA
| | - Claire Jansson-Knodell
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, IN, USA
| | - Edward Krajicek
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, IN, USA
| | - Shanker Das Kundumadam
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, IN, USA
| | - Venkat Nutalapati
- Division of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine, Kansas City, KS, USA
| | | | - Shadi Razmdjou
- Division of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Akira Saito
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, IN, USA
| | - Fayez Sarkis
- Division of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Richard Sutton
- Division of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Antonios Wehbeh
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, IN, USA
| | - Prateek Sharma
- Division of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine, Kansas City, KS, USA.,Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, MO, USA
| | - Madhav Desai
- Division of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine, Kansas City, KS, USA.,Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, MO, USA
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Gifford E, Kalra M, Pochettino A, Greason K, Bhatti U, Oderich G, DeMartino RR, Bower TC. PC004 Early and Late Results of Reconstruction With Renal and Visceral Bypasses During Open Thoracoabdominal Aortic Aneurysm Repair. J Vasc Surg 2017. [DOI: 10.1016/j.jvs.2017.03.266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Alam MS, Ahsan H, Sajjad Z, Beg M, Bhatti U, Enam A, Wasay M. Magnetic resonance spectroscopy of enhancing cerebral lesions: analysis of 78 histopathology proven cases. J PAK MED ASSOC 2014; 64:1141-1145. [PMID: 25823153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To investigate the efficacy of magnetic resonance spectroscopy in differentiating various types of neoplastic and non-neoplastic enhancing cerebral lesions. METHODS The prospective study was conducted from January 2007 to December 2009 at the Department of Radiology, Aga Khan University Hospital, Karachi. All patients with enhancing brain lesions on magnetic resonance imaging who underwent magnetic resonance spectroscopy and a biopsy with histopathological analysis were included in study. The lesions were categorised into neoplastic and non-neoplastic lesions on the basis of spectroscopy findings. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of magnetic resonance spectroscopy were calculated. Predicted probabilities were computed and comparison of median values of metabolites and their ratios was analysed using non-parametric Mann Whitney U test to differentiate between neoplastic and non-neoplastic lesions. RESULTS Of the 102 patients enrolled, 78 (76.5%) comprised the final study sample. There were 53 (68%) male and 25 (32%) female patients with an overall mean age of 40.21 ± 17.69 years (range: 4-76 years). The mean overall size of the lesion was 4.01 ± 1.79 cm, and 61(78%) lesions were neoplastic and 17 (22%) were non-neoplastic. The sensitivity, specificity, positive predictive value and negative predictive value and diagnostic accuracy of magnetic resonance spectroscopy in differentiating neoplastic and non-neoplastic lesions were 90.16%, 64.70%, 90.16%, 64.70% and 78.20% respectively. A cut-off value of 2.55 of Choline/N-Acetyl Aspartate ratio depicted sensitivity of 70% in differentiating the lesions. CONCLUSION Magnetic resonance spectroscopy is a highly sensitive technique in addition to conventional magnetic resonance imaging in characterising and differentiating between neoplastic and non-neoplastic cerebral lesions.
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