Diagnostic Yield of Repeat Lower GI Endoscopy for Recurrent Hematochezia
1
T1396 Diagnostic Yield of Repeat Lower GI Endoscopy for Recurrent Hematochezia Ashish Malhotra, Richard D. Gerkin, Phillip P. Duong, Nooman Gilani Background: Hematochezia is a common clinical presentation. Management typically involves a lower GI endoscopy for diagnostic and/or therapeutic purposes. However, in many of these patients, the source may remain obscure despite multiple exams. The data regarding the yield of repeated colonoscopies in patients with recurrent hematochezia are lacking. Aim: To determine the value of multiple endoscopies for recurrent hematochezia. Methods: Records of all lower GI endoscopies performed for hematochezia at our institution between January 1996 and June 2008 were retrospectively reviewed. Patients with 2 or more endoscopies for hematochezia were selected. Exclusion criteria: suspected or confirmed UGIB, hemorrhoidal bleed, incomplete index exam, inadequate preparation or identifiable source at index. Demographics data including age, sex, and inpatient vs. outpatient setting, ICU admission, total number of exams, interval between exams and any positive findings were recorded. Logistic regression was used to determine predictors of the outcome. A two-tailed p!0.05 was considered significant. Results: There were 105 patients in the study; all but 3 were men. The mean age was 66.6 ( 11.3) years. The number of patients having follow-up endoscopies and the number with their first positive test are listed in Table 1. A total of 29 patients ultimately had identifiable bleeding source (27.6%, 95% CI 19.3-37.2). Factors that were associated with ultimately having a positive test are shown in Table 2. Findings on 2nd test included colonic neoplasiaZ6, colitidiesZ6, angiodysplasiaZ4, rectal ulcerZ3, dieulafoy’sZ2, diverticular bleedZ2 and post-polypectomy bleed Z1. Findings on 3rd endoscopy included radiation proctopathyZ2, colonic neoplasiaZ1, rectal ulcerZ1 and diverticular bleedZ1. In the multivariate model, only the variable % 1 year between any 2 endoscopies was found to be statistically significant as a predictor of ultimately having a positive test. Conclusions: Our data provide first estimate of how many patients (27.6%) will have an identifiable source of hematochezia if a repeat endoscopy be performed for recurrence of symptoms. The yield of a positive finding decreases with each successive test. A shorter interval between two endoscopies seems to provide a better chance of detecting bleeding source. Table 1 Endoscopy # Number having endoscopy Number with 1st positive test % positive 2 105 24 22.9 3 38 5 13.2 R4 9 0 0 Table 2 Variable OR (for D test) p %1 year between any 2 endoscopies 6.91 !0.001 O2 endoscopies 4.58 0.001 T1397 High Definition Chromoendoscopy for the Detection of Rectal Aberrant Crypt Foci Gabriele Delconte, Marguerite E.I. Schipper, Frank P. Vleggaar, Tri Q. Nguyen, Luigi Laghi, Alessandro Repici, Alberto Malesci, Johan Offerhaus, Peter D. Siersema Background and Aim: Aberrant crypt foci (ACF) have emerged as lesions associated with colorectal adenoma and cancer development. High magnification chromoendosocpy (HMC) allows in vivo ACF identification in colorectal mucosa. Using HMC, several inconsistencies such as different rates of agreement between endoscopic and histological findings have been reported. We speculate that this can be attributed to the non-standardized use of this technique. We therefore investigated a more standardized technique, high-definition chromoendscopy (HDC), for the identification of rectal ACF. Methods: Total colonoscopy involving rectal chromoendoscopy was performed using an Olympus CF-H180L and 0.2% methylene blue. An ACF was endoscopically defined as a cluster of crypts, that stained darker, was rounded, had larger diameters, and was slightly elevated compared to the normal mucosa. Biopsies obtained from each ACF were histologically evaluated. Results: Fifteen patients referred for screening underwent total colonoscopy (mean age 61.7 SD 10.2). In total, 34 rectal ACF were identified, with at least one ACF being detected in all patients. Sixteen colorectal lesions including 12 tubulovillous adenomas, 3 advanced tubulovillous adenomas and one invasive cancer were also detected. The mean number of ACF in the 4 patients with advanced adenoma or cancer and in the 5 patients with non-advanced adenoma was 2.5 1.0 and 1.2 0.4 (pZ0.034), respectively. Moreover, a correlation was found between age and increasing number of rectal ACF (rZ0.45; p 0.009). Five (14.7%) ACF could not histologically be evaluated because of lymphoid follicles near the lesion (nZ3) or damaged tissue (nZ2). In the remaining 29 ACF, 5 (17%) had a normal epithelial structure, whereas 11 (38%) and 13 (45%) ACF were classified as non-dysplastic, non-hyperplastic and as non- dysplastic, hyperplastic, respectively. In none of the ACF, dysplastic foci were identified. Conclusion: This is the first study reporting the use of HDC for the detection of rectal ACF. Consistently with data from the literature, we found a higher incidence of rectal ACF in older patients and in patients with advanced adenoma/carcinoma. T1398 IBD and Chronic Diarrhea: When Is Colonoscopy Appropriate? Pascal Juillerat, Se ´verine Schussele ´ Filliettaz, Bernard Burnand, Chantal Arditi, Alastair Windsor, Christoph Beglinger, Robert W. Dubois, Isabelle Peytremann-Bridevaux, Vale´rie Pittet, Jean-Jacques Gonvers, Florian Froehlich, John-Paul Vader Background: The need for endoscopy in the management of Inflammatory Bowel Disease (IBD) and chronic diarrhea (excluding colorectal cancer surveillance) has always been a subject of keen debate and formal evidence is lacking. Real clinical scenarios made available on the web would be of great help in decision-making in clinical practice as to whether colonoscopy is appropriate for a given patient. Methods: A multidisciplinary multinational expert panel (EPAGE II) developed appropriateness criteria based on best published evidence (systematic reviews, clinical trials, guidelines) and experts’ judgement. Using the explicit RAND Appropriateness Method (3 rounds of experts’ votes and a panel meeting) clinical scenarios were judged inappropriate, uncertain, appropriate and necessary. Results: Colonoscopy was considered appropriate in IBD when evaluation of the disease had not previously been undertaken or in the case of worsening or absence of improvement of symptoms with adequate treatment. In Crohn’s disease, however, the situation was considered an uncertain indication for performing colonoscopy in the absence of medical therapy whereas in ulcerative colitis it was appropriate if there had been no recent sigmoidoscopy showing severe disease. Finally, coloscopy was inappropriate for the evaluation of a clinically- improving disease state. Coloscopy was appropriate for chronic uncomplicated diarrhea of unknown etiology (i.e. infection etc. excluded) of more than 4 weeks’ duration, and without prior endoscopic evaluation, independently of patient age. Conclusion: Colonoscopy is appropriate for the initial evaluation of the extent of inflammatory bowel disease, and in the case of worsening/absence of improvement of symptoms despite adequate treatment. In severe ulcerative colitis, however, sigmoidoscopy is a valuable, and safer, option. Colonoscopy is appropriate for chronic (O4 weeks) uncomplicated diarrhea of unknown etiology in the absence of previous endoscopies. EPAGE appropriateness criteria are available on www.epage.ch. T1399 Indications, Efficacy, Complications and Outcome of Colorectal Stenting for Colonic Obstruction: Six Years Experience At a Single Center Consecutive Study Involving 135 Patients Leila Kanafi, Francois Cessot, Anne Le Sidaner, Romain Legros, Benjamin Dallaudiere, Denis Sautereau Introduction: Self-expandable metal stent (SEMS) are used to treat malignant colorectal obstruction (MCRO). SEMS may be used as bridge to surgery or as a palliative treatment. This study aims to evaluate the use of SEMS for MCRO in a single university endoscopic practice center. Aims and Methods: A total of 135 colorectal SEMS were inserted during a 6 years period (July 2001 to February 2008). This retrospective study was realised in a single university hospital center with three senior gastroenterology and four trainees. The included patients presented MCRO with differents clinics symptoms: total or partial obstructive syndrome, others symptoms. The outcome measures where the technical and clinical success and possible differences according to several groups of patients (peritoneal carcinosis; indications; clinical symptoms; using fluoroscopy or not to control the insertion of the stent, length of the stenosis, endoscopic features). Results: Median patients age was 78 years (27 to 98 years). 60% were men and 40% women. The median length of the stenosis was 5 cm. The site of obstruction was: the rectum in 21%, rectosigmoid in 61%, splenic flexure in 6%, transverse in 6%, right colon in 6%. Successful placement was achieved in 123 patients (91,1%) and colonic decompression was achieved in 118 patients (87,4%). SEMS was inserted as a bridge to surgery in 31% and as a palliative treatment in 69%. There where no difference when the stent was inserted before surgery (89%) or as a palliative treatment (90%). The median delay before surgery was 7.5 days. There was differences between several sub-group, clinical success was: 67% for patients with peritoneal carcinosis, 78,9% for patients with complete obstructive symptoms; 89,3% with partial obstructive symptoms. The stent was inserted by endoscopy alone in 66,7% and 33,3% by endoscopy with control by fluoroscopy. Clinical success for the group who had the stent inserted by endoscopy with a fluoroscopic control in 93,2% And with endoscopic control alone in 84,1%The major complication was perforation in 4 patients (4%) and lead to death in 2 patients (1,6%). There where less severe complications in 16%. Median survival after the stent placement was 69 days (one Abstracts AB286 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009 www.giejournal.org
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Transcript of Diagnostic Yield of Repeat Lower GI Endoscopy for Recurrent Hematochezia
Abstracts
T1396
Diagnostic Yield of Repeat Lower GI Endoscopy for Recurrent
HematocheziaAshish Malhotra, Richard D. Gerkin, Phillip P. Duong, Nooman GilaniBackground: Hematochezia is a common clinical presentation. Managementtypically involves a lower GI endoscopy for diagnostic and/or therapeutic purposes.However, in many of these patients, the source may remain obscure despitemultiple exams. The data regarding the yield of repeated colonoscopies in patientswith recurrent hematochezia are lacking. Aim: To determine the value of multipleendoscopies for recurrent hematochezia. Methods: Records of all lower GIendoscopies performed for hematochezia at our institution between January 1996and June 2008 were retrospectively reviewed. Patients with 2 or more endoscopiesfor hematochezia were selected. Exclusion criteria: suspected or confirmed UGIB,hemorrhoidal bleed, incomplete index exam, inadequate preparation oridentifiable source at index. Demographics data including age, sex, and inpatient vs.outpatient setting, ICU admission, total number of exams, interval between examsand any positive findings were recorded. Logistic regression was used to determinepredictors of the outcome. A two-tailed p!0.05 was considered significant. Results:There were 105 patients in the study; all but 3 were men. The mean age was 66.6(�11.3) years. The number of patients having follow-up endoscopies and thenumber with their first positive test are listed in Table 1. A total of 29 patientsultimately had identifiable bleeding source (27.6%, 95% CI 19.3-37.2). Factors thatwere associated with ultimately having a positive test are shown in Table 2. Findingson 2nd test included colonic neoplasiaZ6, colitidiesZ6, angiodysplasiaZ4, rectalulcerZ3, dieulafoy’sZ2, diverticular bleedZ2 and post-polypectomy bleed Z1.Findings on 3rd endoscopy included radiation proctopathyZ2, colonicneoplasiaZ1, rectal ulcerZ1 and diverticular bleedZ1. In the multivariate model,only the variable % 1 year between any 2 endoscopies was found to be statisticallysignificant as a predictor of ultimately having a positive test. Conclusions: Our dataprovide first estimate of how many patients (27.6%) will have an identifiable sourceof hematochezia if a repeat endoscopy be performed for recurrence of symptoms.The yield of a positive finding decreases with each successive test. A shorter intervalbetween two endoscopies seems to provide a better chance of detecting bleedingsource.
Table 1
Endoscopy Number Number with 1st % positive
#AB286 GASTRO
havingendoscopy
INTESTINAL ENDOSC
positive test
OPY Volume 69, No
2
105 24 22.9 3 38 5 13.2 R4 9 0 0Table 2
Variable OR (for D test) p
%1 year between any 2 endoscopies
6.91 !0.001 O2 endoscopies 4.58 0.001T1397
High Definition Chromoendoscopy for the Detection of Rectal
Aberrant Crypt FociGabriele Delconte, Marguerite E.I. Schipper, Frank P. Vleggaar, TriQ. Nguyen, Luigi Laghi, Alessandro Repici, Alberto Malesci,Johan Offerhaus, Peter D. SiersemaBackground and Aim: Aberrant crypt foci (ACF) have emerged as lesions associatedwith colorectal adenoma and cancer development. High magnificationchromoendosocpy (HMC) allows in vivo ACF identification in colorectal mucosa.Using HMC, several inconsistencies such as different rates of agreement betweenendoscopic and histological findings have been reported. We speculate that this canbe attributed to the non-standardized use of this technique. We thereforeinvestigated a more standardized technique, high-definition chromoendscopy(HDC), for the identification of rectal ACF. Methods: Total colonoscopy involvingrectal chromoendoscopy was performed using an Olympus CF-H180L and 0.2%methylene blue. An ACF was endoscopically defined as a cluster of crypts, thatstained darker, was rounded, had larger diameters, and was slightly elevatedcompared to the normal mucosa. Biopsies obtained from each ACF werehistologically evaluated. Results: Fifteen patients referred for screening underwenttotal colonoscopy (mean age 61.7 SD � 10.2). In total, 34 rectal ACF wereidentified, with at least one ACF being detected in all patients. Sixteen colorectallesions including 12 tubulovillous adenomas, 3 advanced tubulovillous adenomasand one invasive cancer were also detected. The mean number of ACF in the 4patients with advanced adenoma or cancer and in the 5 patients with non-advancedadenoma was 2.5 � 1.0 and 1.2 � 0.4 (pZ0.034), respectively. Moreover,a correlation was found between age and increasing number of rectal ACF (rZ0.45;p 0.009). Five (14.7%) ACF could not histologically be evaluated because of
. 5 : 2009
lymphoid follicles near the lesion (nZ3) or damaged tissue (nZ2). In theremaining 29 ACF, 5 (17%) had a normal epithelial structure, whereas 11 (38%) and13 (45%) ACF were classified as non-dysplastic, non-hyperplastic and as non-dysplastic, hyperplastic, respectively. In none of the ACF, dysplastic foci wereidentified. Conclusion: This is the first study reporting the use of HDC for thedetection of rectal ACF. Consistently with data from the literature, we founda higher incidence of rectal ACF in older patients and in patients with advancedadenoma/carcinoma.
T1398
IBD and Chronic Diarrhea: When Is Colonoscopy Appropriate?Pascal Juillerat, Severine Schussele Filliettaz, Bernard Burnand,Chantal Arditi, Alastair Windsor, Christoph Beglinger, Robert W. Dubois,Isabelle Peytremann-Bridevaux, Valerie Pittet, Jean-Jacques Gonvers,Florian Froehlich, John-Paul VaderBackground: The need for endoscopy in the management of Inflammatory BowelDisease (IBD) and chronic diarrhea (excluding colorectal cancer surveillance) hasalways been a subject of keen debate and formal evidence is lacking. Real clinicalscenarios made available on the web would be of great help in decision-making inclinical practice as to whether colonoscopy is appropriate for a given patient.Methods: A multidisciplinary multinational expert panel (EPAGE II) developedappropriateness criteria based on best published evidence (systematic reviews,clinical trials, guidelines) and experts’ judgement. Using the explicit RANDAppropriateness Method (3 rounds of experts’ votes and a panel meeting) clinicalscenarios were judged inappropriate, uncertain, appropriate and necessary. Results:Colonoscopy was considered appropriate in IBD when evaluation of the diseasehad not previously been undertaken or in the case of worsening or absence ofimprovement of symptoms with adequate treatment. In Crohn’s disease, however,the situation was considered an uncertain indication for performing colonoscopy inthe absence of medical therapy whereas in ulcerative colitis it was appropriate ifthere had been no recent sigmoidoscopy showing severe disease. Finally, coloscopywas inappropriate for the evaluation of a clinically- improving disease state.Coloscopy was appropriate for chronic uncomplicated diarrhea of unknownetiology (i.e. infection etc. excluded) of more than 4 weeks’ duration, and withoutprior endoscopic evaluation, independently of patient age. Conclusion:Colonoscopy is appropriate for the initial evaluation of the extent of inflammatorybowel disease, and in the case of worsening/absence of improvement of symptomsdespite adequate treatment. In severe ulcerative colitis, however, sigmoidoscopy isa valuable, and safer, option. Colonoscopy is appropriate for chronic (O4 weeks)uncomplicated diarrhea of unknown etiology in the absence of previousendoscopies. EPAGE appropriateness criteria are available on www.epage.ch.
T1399
Indications, Efficacy, Complications and Outcome of Colorectal
Stenting for Colonic Obstruction: Six Years Experience At
a Single Center Consecutive Study Involving 135 PatientsLeila Kanafi, Francois Cessot, Anne Le Sidaner, Romain Legros,Benjamin Dallaudiere, Denis SautereauIntroduction: Self-expandable metal stent (SEMS) are used to treat malignantcolorectal obstruction (MCRO). SEMS may be used as bridge to surgery or asa palliative treatment. This study aims to evaluate the use of SEMS for MCRO ina single university endoscopic practice center. Aims and Methods: A total of 135colorectal SEMS were inserted during a 6 years period (July 2001 to February 2008).This retrospective study was realised in a single university hospital center withthree senior gastroenterology and four trainees. The included patients presentedMCRO with differents clinics symptoms: total or partial obstructive syndrome,others symptoms. The outcome measures where the technical and clinical successand possible differences according to several groups of patients (peritonealcarcinosis; indications; clinical symptoms; using fluoroscopy or not to control theinsertion of the stent, length of the stenosis, endoscopic features). Results: Medianpatients age was 78 years (27 to 98 years). 60% were men and 40% women. Themedian length of the stenosis was 5 cm. The site of obstruction was: the rectum in21%, rectosigmoid in 61%, splenic flexure in 6%, transverse in 6%, right colon in 6%.Successful placement was achieved in 123 patients (91,1%) and colonicdecompression was achieved in 118 patients (87,4%). SEMS was inserted as a bridgeto surgery in 31% and as a palliative treatment in 69%. There where no differencewhen the stent was inserted before surgery (89%) or as a palliative treatment (90%).The median delay before surgery was 7.5 days. There was differences betweenseveral sub-group, clinical success was: 67% for patients with peritoneal carcinosis,78,9% for patients with complete obstructive symptoms; 89,3% with partialobstructive symptoms. The stent was inserted by endoscopy alone in 66,7% and33,3% by endoscopy with control by fluoroscopy. Clinical success for the group whohad the stent inserted by endoscopy with a fluoroscopic control in 93,2% And withendoscopic control alone in 84,1%The major complication was perforation in 4patients (4%) and lead to death in 2 patients (1,6%). There where less severecomplications in 16%. Median survival after the stent placement was 69 days (one
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