Implementation of screening and preventive strategies in liver transplant candidates
1
GERD symptoms, 44% felt cure had no effect or were not sure, and 12% felt cure worsened GERD. 80% of PCPs were testing pts with GERD symptoms (heartburn and/or regurgitation) for Hp at least sometimes. When treating a pt with persistent nocturnal heartburn despite a PPI QD, 36% of PCPs would increase to PPI BID while 32% would add an H2RA QHS. 18% reported that 10% of GERD patients were taking a PPI & H2RA. Conclusions: PCPs have accepted recommendations to screen for Barrett’s esophagus in pts with chronic GERD. Most can order “open access” EGD and do so prior to or shortly after starting therapy. Despite a lack of evidence, a majority felt that PPIs alter the natural history of Barrett’s while few had a similar opinion about surgery. Many PCPs felt that treating Hp was of benefit to GERD and despite no recommendations to do so, 80% were testing pts with only GERD for Hp. Adding an H2RA QHS was as popular as PPI BID for persistent nocturnal heartburn. Further GERD education for PCPs is warranted. 708 LONG–TERM OUTCOME OF PATIENTS WITH IDIOPATHIC GASTROPARESIS Zhenzhou Feng, M.D. and Ronald Fogel, M.D.*. Gastroenterology, Henry Ford Hospital, Detroit, MI. Purpose: Idiopathic gastroparesis is defined as delayed gastric emptying without medical or mechanical conditions that could cause this problem. To date, little is known regarding the natural history of this condition after initiation of prokinetic therapy. The goal of this study was to characterize the outcome of patients after treatment. Methods: Using the Nuclear Medicine Database we identified 144 patients with delayed gastric emptying. Twenty six patients (age 16 years) had idiopathic gastroparesis. Data abstracted included demographics, present- ing symptoms, associated medical conditions, gastric emptying results, treatment duration, and response to treatment. Results are expressed as mean /– SD. Results: Mean age of subjects was 46 19 years, 85% female, 69% Caucasian and 23% African American. The most frequent presenting symptoms were nausea (62%), dyspepsia (58%), vomiting (50%), GERD (27%), early satiety (27%), dysphagia (19%), and bloating (19%). Twenty– one patients had an EGD. Gastritis was seen in 67% and esophagitis in 43%. The mean T 1 /2 of the initial gastric emptying was 155 /– 76 min. Seven patients had significantly prolonged gastric emptying studies in which T 1 /2 could not be determined. Twenty–three patients received pharmacological therapy. One prokinetic agent was given to 16 patients, seven patients required 2 different prokinetic agents. The initial therapy was cisapride (57%), oral metoclopramide (35%), and IV metoclopramide (8%). Three patients switched from oral metoclopramide to cisparide, two patients switched from cisparide to oral metoclopramide, one patient switched from oral metoclopramide to erythomycin. For patients receiving only one drug, the mean duration of therapy was 465 /– 559 days. Patients receiving two drugs had a mean duration of therapy of 747 /– 600 days. Symtom improvement was seen in 69% of patients receiving cisapride within 100 /– 49 days and in 64% receiving oral metoclopramide within 99 /– 120 days. Follow– up after treatment was 1530 /– 862 days. At the end of follow– up, only two patients still received prokinetic therapy. Both were symptomatic. Eight patients had minimal symptoms of gastroparesis but did not require prokinetic treatment. The remainder were symptom free. Conclusions: Most patients with symptomatic idiopathic gastroparesis require initial treatment with prokinetic therapy but indefinite treatment is not needed because symptoms appear to diminish with time. 709 IMPLEMENTATION OF SCREENING AND PREVENTIVE STRATEGIES IN LIVER TRANSPLANT CANDIDATES Guilherme Macedo, M.D.,FACG*, Susana Lopes, M.D., Sonia Barroso, M.D., Pedro Moutinho Ribeiro, M.D. and Jose Costa Maia, M.D. Gastroenterology Unit, H.S.Joa ˜o, Porto, Portugal. Purpose: Several recommendations have been established (Baveno III) regarding diagnosis of esophageal varices and primary or secondary pro- phylaxis of variceal bleeding. Also, hepatocellular carcinoma screening has been of great concern in end stage liver disease patients. We have assessed the role of pretransplant evaluation protocol in adopt- ing new pharmacological or instrumental (endoscopic or radiological) practices in prevention and treatment of these patients. Methods: Between May 94 and April 02 we have evaluated 210 cirrhotic patients for elective liver transplant (OLT). Alcoholic cirrhosis was the dominant etiology (83 patients, 39%), along with HCV infection (in 58 patients, 27%) and HBV infection ( in 35 patients, 16%). Autoimmune cholestatic cirrhosis was present in 11 patients (5%), metabolic diseases in 23 (10%) and cryptogenic in 4 (2%). Pre OLT evaluation included: endos- copy, colonoscopy (in patients older than 45), ultrasound (Doppler), CT scan, abdominal MMR and alpha fetoprotein, and in doubtful cases, US guided liver biopsy. Results: Although all patients presented grade II/III esophageal varices or portal hipertensive gastropathy, 58 (28%) were neither medicated with blockers nor were enrolled in an erradication program of previous bleed- ing varices. Endoscopy had not been performed in 18 patients (9%). Ultrasound or alpha fetoprotein had not been regularly assessed in 41 patients (22%). Hepatocellular carcinoma was diagnosed in 21 patients, and in 6, a curative ressection was achieved. TIPS were performed in 3 patients, because of recurrent bleeding. Following “de novo” diagnosis of hemo- chromatosis and Wilson’s, after dosing iron and copper in transjugular liver biopsies, 28 relatives of index cases had to be evaluated. Conclusions: Evaluation for OLT enable us to promote a considerable number of prophylatic or therapeutic measures, supporting the need for an intense pedagogic diffusion of the current good practice guidelines con- cerning chronic liver disease patients. 710 NON–STEROIDAL ANTI–INFLAMMATORY DRUG (NSAID) USE AND PREVENTION OF COLORECTAL CANCER (CRC): A META–ANALYSIS Jia–Qing Huang, M.D., Katica Sumanac, M.D. and Richard H. Hunt, M.D., FACG*. Div. of Gastroenterology, McMaster Univ. Medical Ctr., Hamilton, Canada. Purpose: Combined evidence from epidemiological, clinical and animal studies has shown that aspirin/NSAIDs are effective for reducing the risk of developing colorectal cancer. However, the magnitude of effect remains unevaluated. The purpose is to systematically review the epidemiological literature on NSAID use and risk of colorectal cancer and to evaluate if long–term use of NSAIDs prevents colorectal cancer and the magnitude of effect. Methods: A comprehensive search to March 2002 was conducted in Medline, PubMed and Cochrane databases using the following keywords: non–steroidal anti–inflammatory agents, colorectal neoplasms, aspirin, NSAIDs, and cancer. Studies included: 1. case– control or cohort studies of long–term NSAIDs/aspirin use and development of colrectal cancer, with age and gender matched controls; 2. explicit description of NSAID expo- sure with raw data on number of users; 3. clear description of diagnosis of colorectal cancer; 4. adult population and article published in English. Excluded: case reports, cohort studies with no data on person–yrs. of exposure, patients with inflammatory bowel disease, meeting abstracts, benign colorectal tumors, and duplicate publications. Sources of any het- erogeneity were explored. A random effects model was used in all analyses. Results: Of 300 potential citations, 13 studies met the eligibility criteria. In 5 cohort studies, the incidence of CRC was 5 per 10,000 person–yrs. in NSAID takers and 5.3 per 10,000 person–yrs. in controls, giving a relative risk of 0.81 (95% CI 0.72– 0.92). Test of heterogeneity was non–signifi- cant. Conclusions: Use of aspirin or NSAIDs may be effective for preventing colorectal cancer and may lower the relative risk by 24% overall and 32% when used over 2 yrs. Both aspirin and non–aspirin NSAIDs are equally S232 Abstracts AJG – Vol. 97, No. 9, Suppl., 2002
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Transcript of Implementation of screening and preventive strategies in liver transplant candidates
GERD symptoms, 44% felt cure had no effect or were not sure, and 12%felt cure worsened GERD. 80% of PCPs were testing pts with GERDsymptoms (heartburn and/or regurgitation) for Hp at least sometimes.When treating a pt with persistent nocturnal heartburn despite a PPI QD,36% of PCPs would increase to PPI BID while 32% would add an H2RAQHS. 18% reported that �10% of GERD patients were taking a PPI &H2RA.Conclusions: PCPs have accepted recommendations to screen for Barrett’sesophagus in pts with chronic GERD. Most can order “open access” EGDand do so prior to or shortly after starting therapy. Despite a lack ofevidence, a majority felt that PPIs alter the natural history of Barrett’s whilefew had a similar opinion about surgery. Many PCPs felt that treating Hpwas of benefit to GERD and despite no recommendations to do so, 80%were testing pts with only GERD for Hp. Adding an H2RA QHS was aspopular as PPI BID for persistent nocturnal heartburn. Further GERDeducation for PCPs is warranted.
708
LONG–TERM OUTCOME OF PATIENTS WITH IDIOPATHICGASTROPARESISZhenzhou Feng, M.D. and Ronald Fogel, M.D.*. Gastroenterology,Henry Ford Hospital, Detroit, MI.
Purpose: Idiopathic gastroparesis is defined as delayed gastric emptyingwithout medical or mechanical conditions that could cause this problem. Todate, little is known regarding the natural history of this condition afterinitiation of prokinetic therapy. The goal of this study was to characterizethe outcome of patients after treatment.Methods: Using the Nuclear Medicine Database we identified 144 patientswith delayed gastric emptying. Twenty six patients (age �16 years) hadidiopathic gastroparesis. Data abstracted included demographics, present-ing symptoms, associated medical conditions, gastric emptying results,treatment duration, and response to treatment. Results are expressed asmean �/– SD.Results: Mean age of subjects was 46 � 19 years, 85% female, 69%Caucasian and 23% African American. The most frequent presentingsymptoms were nausea (62%), dyspepsia (58%), vomiting (50%), GERD(27%), early satiety (27%), dysphagia (19%), and bloating (19%). Twenty–one patients had an EGD. Gastritis was seen in 67% and esophagitis in43%. The mean T 1⁄2 of the initial gastric emptying was 155 �/– 76 min.Seven patients had significantly prolonged gastric emptying studies inwhich T 1⁄2 could not be determined. Twenty–three patients receivedpharmacological therapy. One prokinetic agent was given to 16 patients,seven patients required 2 different prokinetic agents. The initial therapywas cisapride (57%), oral metoclopramide (35%), and IV metoclopramide(8%). Three patients switched from oral metoclopramide to cisparide, twopatients switched from cisparide to oral metoclopramide, one patientswitched from oral metoclopramide to erythomycin. For patients receivingonly one drug, the mean duration of therapy was 465 �/– 559 days. Patientsreceiving two drugs had a mean duration of therapy of 747 �/– 600 days.Symtom improvement was seen in 69% of patients receiving cisapridewithin 100 �/– 49 days and in 64% receiving oral metoclopramide within99 �/– 120 days. Follow–up after treatment was 1530 �/– 862 days. At theend of follow–up, only two patients still received prokinetic therapy. Bothwere symptomatic. Eight patients had minimal symptoms of gastroparesisbut did not require prokinetic treatment. The remainder were symptom free.Conclusions: Most patients with symptomatic idiopathic gastroparesisrequire initial treatment with prokinetic therapy but indefinite treatment isnot needed because symptoms appear to diminish with time.
709
IMPLEMENTATION OF SCREENING AND PREVENTIVESTRATEGIES IN LIVER TRANSPLANT CANDIDATESGuilherme Macedo, M.D.,FACG*, Susana Lopes, M.D., Sonia Barroso,M.D., Pedro Moutinho Ribeiro, M.D. and Jose Costa Maia, M.D.Gastroenterology Unit, H.S.Joao, Porto, Portugal.
Purpose: Several recommendations have been established (Baveno III)regarding diagnosis of esophageal varices and primary or secondary pro-phylaxis of variceal bleeding. Also, hepatocellular carcinoma screening hasbeen of great concern in end stage liver disease patients.
We have assessed the role of pretransplant evaluation protocol in adopt-ing new pharmacological or instrumental (endoscopic or radiological)practices in prevention and treatment of these patients.Methods: Between May 94 and April 02 we have evaluated 210 cirrhoticpatients for elective liver transplant (OLT). Alcoholic cirrhosis was thedominant etiology (83 patients, 39%), along with HCV infection (in 58patients, 27%) and HBV infection ( in 35 patients, 16%). Autoimmunecholestatic cirrhosis was present in 11 patients (5%), metabolic diseases in23 (10%) and cryptogenic in 4 (2%). Pre OLT evaluation included: endos-copy, colonoscopy (in patients older than 45), ultrasound (Doppler), CTscan, abdominal MMR and alpha fetoprotein, and in doubtful cases, USguided liver biopsy.Results: Although all patients presented grade II/III esophageal varices orportal hipertensive gastropathy, 58 (28%) were neither medicated with�blockers nor were enrolled in an erradication program of previous bleed-ing varices. Endoscopy had not been performed in 18 patients (9%).Ultrasound or alpha fetoprotein had not been regularly assessed in 41patients (22%). Hepatocellular carcinoma was diagnosed in 21 patients, andin 6, a curative ressection was achieved. TIPS were performed in 3 patients,because of recurrent bleeding. Following “de novo” diagnosis of hemo-chromatosis and Wilson’s, after dosing iron and copper in transjugular liverbiopsies, 28 relatives of index cases had to be evaluated.Conclusions: Evaluation for OLT enable us to promote a considerablenumber of prophylatic or therapeutic measures, supporting the need for anintense pedagogic diffusion of the current good practice guidelines con-cerning chronic liver disease patients.
710
NON–STEROIDAL ANTI–INFLAMMATORY DRUG (NSAID)USE AND PREVENTION OF COLORECTAL CANCER (CRC): AMETA–ANALYSISJia–Qing Huang, M.D., Katica Sumanac, M.D. and Richard H. Hunt,M.D., FACG*. Div. of Gastroenterology, McMaster Univ. Medical Ctr.,Hamilton, Canada.
Purpose: Combined evidence from epidemiological, clinical and animalstudies has shown that aspirin/NSAIDs are effective for reducing the riskof developing colorectal cancer. However, the magnitude of effect remainsunevaluated. The purpose is to systematically review the epidemiologicalliterature on NSAID use and risk of colorectal cancer and to evaluate iflong–term use of NSAIDs prevents colorectal cancer and the magnitude ofeffect.Methods: A comprehensive search to March 2002 was conducted inMedline, PubMed and Cochrane databases using the following keywords:non–steroidal anti–inflammatory agents, colorectal neoplasms, aspirin,NSAIDs, and cancer. Studies included: 1. case–control or cohort studies oflong–term NSAIDs/aspirin use and development of colrectal cancer, withage and gender matched controls; 2. explicit description of NSAID expo-sure with raw data on number of users; 3. clear description of diagnosis ofcolorectal cancer; 4. adult population and article published in English.Excluded: case reports, cohort studies with no data on person–yrs. ofexposure, patients with inflammatory bowel disease, meeting abstracts,benign colorectal tumors, and duplicate publications. Sources of any het-erogeneity were explored. A random effects model was used in all analyses.Results: Of 300 potential citations, 13 studies met the eligibility criteria. In5 cohort studies, the incidence of CRC was 5 per 10,000 person–yrs. inNSAID takers and 5.3 per 10,000 person–yrs. in controls, giving a relativerisk of 0.81 (95% CI 0.72–0.92). Test of heterogeneity was non–signifi-cant.Conclusions: Use of aspirin or NSAIDs may be effective for preventingcolorectal cancer and may lower the relative risk by 24% overall and 32%when used over 2 yrs. Both aspirin and non–aspirin NSAIDs are equally
S232 Abstracts AJG – Vol. 97, No. 9, Suppl., 2002
