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Journal: Gastrointestinal endoscopy

167

INTRODUCTION: We previously derived and validated the AIMS65 score, a mortality prognostic scale for upper GI bleeding (UGIB). OBJECTIVE: To validate the AIMS65 score in a different patient population and compare it with the Glasgow-Blatchford risk score (GBRS). DESIGN: Retrospective cohort study. PATIENTS: Adults with a primary diagnosis of UGIB. MAIN OUTCOME MEASUREMENTS: Primary outcome: inpatient mortality. Secondary outcomes: composite clinical endpoint of inpatient mortality, rebleeding, and endoscopic, radiologic or surgical intervention; blood transfusion; intensive care unit admission; rebleeding; length of stay; timing of endoscopy. The area under the receiver-operating characteristic curve (AUROC) was calculated for each score. RESULTS: Of the 278 study patients, 6.5% died and 35% experienced the composite clinical endpoint. The AIMS65 score was superior in predicting inpatient mortality (AUROC, 0.93 vs 0.68; P < .001), whereas the GBRS was superior in predicting blood transfusions (AUROC, 0.85 vs 0.65; P < .01) The 2 scores were similar in predicting the composite clinical endpoint (AUROC, 0.62 vs 0.68; P = .13) as well as the secondary outcomes. A GBRS of 10 and 12 or more maximized the sum of the sensitivity and specificity for inpatient mortality and rebleeding, respectively. The cutoff was 2 or more for the AIMS65 score for both outcomes. LIMITATIONS: Retrospective, single-center study. CONCLUSION: The AIMS65 score is superior to the GBRS in predicting inpatient mortality from UGIB, whereas the GBRS is superior for predicting blood transfusion. Both scores are similar in predicting the composite clinical endpoint and other outcomes in clinical care and resource use.

Concepts: Cohort study, Blood, Surgery, Type I and type II errors, Sensitivity and specificity, Binary classification, Blood transfusion, Upper gastrointestinal bleeding

28

Pancreatitis is the most common major complication of ERCP and precut endoscopic sphincterotomy (ES). Prophylactic pancreatic duct (PD) stent placement has been shown to reduce the incidence and severity of post-ERCP pancreatitis (PEP) in high-risk settings.

Concepts: Pancreas, Bile, Endoscopic retrograde cholangiopancreatography, Pancreatic duct

28

BACKGROUND: Chromo-zoom endoscopy has been demonstrated to be valuable in assessing the degree of intestinal villous atrophy in patients with suspected celiac disease. OBJECTIVE: To evaluate the diagnostic accuracy of chromo-zoom endoscopy in patients with difficult diagnosis because of nonconcordant test results and/or the confounding of a gluten-free diet initiated before an appropriate diagnosis of celiac disease and to compare the findings to a recent reference standard, the in vitro gliadin challenge test. DESIGN: Prospective, case-control study. SETTING: Tertiary-care referral hospital. PATIENTS: Patients without celiac disease (negative control group, n = 9), patients with celiac disease (positive control group, n = 41), and patients with difficult diagnosis (n = 27). INTERVENTION: Chromo-endoscopy with indigo carmine and endoscopic zoom-magnification were performed. Duodenal fragments were collected for the in vitro gliadin challenge test. The area under the receiver operating characteristic curve (ROC) was used for statistical analyses on accuracy. MAIN OUTCOME MEASUREMENTS: Diagnostic accuracy of chromo-zoom endoscopy for detection of mucosal abnormalities in patients with difficult diagnosis. RESULTS: Chromo-zoom endoscopy had a high accuracy for celiac disease diagnosis in analyses on negative controls and positive controls (area under roc = 0.99). In the difficult diagnosis group, the accuracy of chromo-zoom endoscopy was lower (area under roc = 0.83), but it increased after exclusion of patients with celiac disease on gluten-free diet (area under roc = 0.88). LIMITATIONS: There was a 4% failure rate in the ability to cultivate biopsies. Also, the study was done at an academic medical center. CONCLUSION: Chromo-zoom endoscopy has high accuracy for cases of difficult diagnosis of celiac disease but only in untreated patients with celiac disease.

Concepts: Scientific control, Wheat, Confounding, Case-control study, Receiver operating characteristic, Coeliac disease, Gluten, Gluten-free diet

27

Nonvariceal upper GI bleeding (NVUGIB) that occurs in patients already hospitalized for another condition is associated with increased mortality, but outcome predictors have not been consistently identified.

Concepts: Hospital, Prediction, Upper gastrointestinal bleeding

27

The American Society of Anesthesiologists (ASA) physical status classification is a measurement of comorbidity and a predictor of perioperative morbidity and mortality.

Concepts: ASA physical status classification system

26

Extracorporeal shock wave lithotripsy (ESWL) for difficult common bile duct (CBD) stones is a safe and effective treatment strategy allowing for bile duct clearance in approximately 90% of patients with a low incidence of mild adverse events.

Concepts: Clinical trial, Bile duct, Lithotriptor, Common bile duct, Choledocholithiasis

24

Diminutive (1-5 mm) and small (6-9 mm) polyps comprise 90% of detected lesions during colonoscopy and rarely contain advanced histology or colorectal cancer (CRC). Routine removal of these lesions results in a significant burden to colonoscopy programs. At the same time, the risk for progression of these polyps to CRC is unclear. We performed a systematic review to explore the natural history of diminutive and small colorectal polyps.

Concepts: Cancer, Systematic review, Colorectal cancer, Ulcerative colitis, Colon, Colorectal polyp, Sigmoidoscopy, History of science

24

Perforation is the adverse event of greatest concern during colorectal endoscopic submucosal dissection (ESD). Accurate risk prediction of perforation may enable prevention strategies and selection of the most efficient therapeutic option. This study aimed to develop and validate a risk prediction model for ESD-induced perforation.

24

BACKGROUND: Endoscopic resection of large colorectal lesions is associated with high complication rates. OBJECTIVE: To evaluate the effect of prophylactic clip closure of polypectomy sites after resection of large (≥2 cm) sessile and flat colorectal lesions. DESIGN: Retrospective study. SETTING: Tertiary referral center. PATIENTS AND INTERVENTIONS: Patients with lesions 2 cm or larger who underwent EMR performed by using low-power coagulation current between January 2000 and February 2012. Beginning in June 2006, polypectomy sites were prophylactically closed with clips when possible. Patients had telephone follow-up at 30 days or later to track complications. MAIN OUTCOME MEASUREMENTS: Delayed hemorrhage, postpolypectomy syndrome, and perforation. RESULTS: There were 524 lesions 2 cm or larger in 463 patients, of which 247 (47.1%) were not clipped, 52 (9.9%) were partially clipped, and 225 (42.9%) were fully clipped. There were 31 delayed hemorrhages, 2 perforations, and 6 cases of postpolypectomy syndrome. The delayed hemorrhage rate was 9.7% in the not clipped group versus 1.8% in the fully clipped group. Multivariate analysis showed that not clipping (odds ratio [OR] 6.0; 95% CI, 2.0-18.5), location proximal to the splenic flexure (OR 2.9; 95% CI, 1.05-8.1), and polyp size (OR 1.3; 95% CI, 1.1-1.7 for each 10-mm increase in size) were associated with delayed bleeding. LIMITATION: Retrospective design. CONCLUSIONS: Prophylactic clipping of resection sites after endoscopic removal of large (≥2 cm) colorectal lesions using low-power coagulation current reduced the risk of delayed postpolypectomy hemorrhage. A randomized, prospective trial of clipping large polypectomy sites is warranted.

Concepts: Blood, Colon, Colonoscopy, Hemostasis, Bleeding, Self number, Video clip, Clip

21

Colonoscopy is the most commonly performed endoscopic procedure and overall is considered a low-risk procedure. However, adverse events (AEs) related to this routinely performed procedure for screening, diagnostic, or therapeutic purposes are an important clinical consideration. The purpose of this document from the American Society for Gastrointestinal Endoscopy’s Standards of Practice Committee is to provide an update on estimates of AEs related to colonoscopy in an evidence-based fashion. A systematic review and meta-analysis of population-based studies was conducted for the 3 most common and important serious AEs (bleeding, perforation, and mortality). In addition, this document includes an updated systematic review and meta-analysis of serious AEs (bleeding and perforation) related to EMR and endoscopic submucosal dissection for large colon polyps. Finally, a narrative review of other colonoscopy-related serious AEs and those related to specific colonic interventions is included.