Faculty Bibliography

INTRODUCTION: Small intestinal bacterial overgrowth (SIBO) has clinical overlap with irritable bowel syndrome (IBS) and is diagnosed either by endoscopic small bowel aspiration (SBA) with quantitative bacterial culture or hydrogen breath testing (BT). SBA is invasive and lacks standardization and BT has questionable accuracy and unreliable performance.
METHOD(S): Qualitative phone interviews with 7 GIs/3 IBS experts explored unmet needs in SIBO diagnosis and gathered feedback on a novel smart capsule bacterial detection system (SCBDS)^-an ingestible capsule with an integrated assay for wirelessly determining small intestinal total bacterial count based on an FDA-approved threshold of $10⁵ CFU/ml. A quantitative online survey of 28 academic and 62 community GIs assessed practice patterns and preferred clinical characteristics of SCBDS.
RESULT(S): GIs saw 77 IBS and 22 SIBO patients on average per month. Suspected SIBO patients (36%) were formally diagnosed by BT with academic GIs placing a greater importance on a formal diagnosis rather than empiric antibiotic therapy. 10% of practices performed SBA for SIBO diagnosis (Figure 1). SIBO diagnosis was evaluated by BT in 47% of patients with only a fraction of GIs giving high ratings for BT accuracy. Empiric antibiotic therapy was performed in ;50% of suspected SIBO patients across both settings, but 91% were at least somewhat concerned with this practice and 60% were unsatisfied with all current diagnostic options (Figure 2). Insufficient accuracy was the most frequently selected diagnostic unmet need, with 58% of GIs selecting it as one of the greatest unmet needs, followed by difficulty in interpreting results (48%) (Figure 3). Over 70% of GIs indicated that SCBDS would be more accurate than BT and would recommend it to almost two-thirds of patients evaluated for SIBO and to one-third for IBS. Two-thirds of GIs also anticipated using SCBDS first over empiric antibiotic therapy alone. In addition, 59% of BT users and 66% performing SBA would replace these methods with SCBDS.
CONCLUSION(S): GIs in both community and academic settings expressed a significant unmet need in SIBO diagnosis driven by BT performance limitations, and only a small minority of GIs were performing SBA to diagnose SIBO. A perceived strength of an FDA-approved SCBDS would be improved accuracy, interpretation and precision as compared to BT, with the majority of GIs suggesting they would replace conventional SIBO diagnostics with such a technology

INTRODUCTION: Esophageal food impaction (EFI) is a common initial presentation of eo-sinophilic esophagitis (EoE). Patients presenting with EFI requiring endoscopic intervention present an opportunity to obtain esophageal biopsies to evaluate for EoE and optimize diagnostic yield before initiation of empiric treatment. We aimed to evaluate practices of esophageal biopsy at time of EFI at our institution and identify missed opportunities to diagnose EoE.
METHOD(S): We performed a single center retrospective chart review on a subset of adult patients from 10/2015 -1/2020 who presented to NYU Langone Health with EFI. Patients who underwent upper endoscopy (EGD) and were found to have a retained esophageal food bolus were included. Those with prior diagnosis of EoE were excluded. Proportions were compared using Chi-square or Fisher's exact test, and rank sum tests were used to compare continuous variables. Logistic regression was used to assess factors associated with subsequent need for diagnostic EGD.
RESULT(S): 123 patients with EFI were reviewed, 50 (40.7%) were biopsied at the time of EGD (Table 1). Among those biopsied, a new diagnosis of EoE was found in 52%. Of the patients who did not undergo biopsy at index EGD, 23% underwent repeat EGD at our institution and were found to have a new EoE diagnosis. Biopsies performed during EGD for EFI did appear to decrease the need for repeat procedure (OR 0.63, 95% CI 0.25-1.63), although not statistically significant. Patients with furrows were more likely to be biopsied however the report of other classic endoscopic features of EoE (such as exudates, ring, stricture, edema), was not significantly associated with the rate of biopsy (Table 2). Time of procedure and history of prior EFI also did not appear to influence rate of biopsy.
CONCLUSION(S): Biopsy at the time of EFI is important to obtain a timely diagnosis of EoE. At our center, less than half of patients were biopsied at time of initial EGD for EFI, and over half of those biopsied were diagnosed with EoE. The diagnosis of EoE was missed in 23% patients who were not biopsied at time of EFI, and on subsequent EGD with biopsy were found to have EoE. This delay in biopsy likely leads to unnecessary EGDs and more patients who are unaware of their diagnosis. Future educational initiatives aimed at GI providers are needed to improve rates of biopsies during initial EGD for EFI to reduce the need for additional diagnostic procedures

The American Neurogastroenterology and Motility Society Task Force recommends that gastrointestinal motility procedures should be performed in motility laboratories adhering to the strict recommendations and personal protective equipment (PPE) measures to protect patients, ancillary staff, and motility allied health professionals. When available and within constraints of institutional guidelines, it is preferable for patients scheduled for motility procedures to complete a coronavirus disease 2019 (COVID-19) test within 48 hours before their procedure, similar to the recommendations before endoscopy made by gastroenterology societies. COVID-19 test results must be documented before performing procedures. If procedures are to be performed without a COVID-19 test, full PPE use is recommended, along with all social distancing and infection control measures. Because patients with suspected motility disorders may require multiple procedures, sequential scheduling of procedures should be considered to minimize need for repeat COVID-19 testing. The strategies for and timing of procedure(s) should be adapted, taking into consideration local institutional standards, with the provision for screening without testing in low prevalence areas. If tested positive for COVID-19, subsequent negative testing may be required before scheduling a motility procedure (timing is variable). Specific recommendations for each motility procedure including triaging, indications, PPE use, and alternatives to motility procedures are detailed in the document. These recommendations may evolve as understanding of virus transmission and prevalence of COVID-19 infection in the community changes over the upcoming months.

OBJECTIVES/OBJECTIVE:Competency-based medical education (CBME) for interpretation of esophageal manometry is lacking; therefore, motility experts and instructional designers developed the esophageal manometry competency (EMC) program: a personalized, adaptive learning program for interpretation of esophageal manometry. The aim of this study was to implement EMC among Gastroenterology (GI) trainees and assess the impact of EMC on competency in manometry interpretation. METHODS:GI fellows across 14 fellowship programs were invited to complete EMC from February 2018 to October 2018. EMC includes an introductory video, baseline assessment of manometry interpretation, individualized learning pathways, and final assessment of manometry interpretation. The primary outcome was competency for interpretation in 7 individual skill sets. RESULTS:Forty-four GI trainees completed EMC. Participants completed 30 cases, each including 7 skill sets. At baseline, 4 (9%) participants achieved competency for all 7 skills compared with 24 (55%) at final assessment (P < 0.001). Competency in individual skills increased from a median of 4 skills at baseline to 7 at final assessment (P < 0.001). The greatest increase in skill competency was for diagnosis (Baseline: 11% vs Final: 68%; P < 0.001). Accuracy improved for distinguishing between 5 diagnostic groups and was highest for the Outflow obstructive motility disorder (Baseline: 49% vs Final: 76%; P < 0.001) and Normal motor function (50% vs 80%; P < 0.001). DISCUSSION/CONCLUSIONS:This prospective multicenter implementation study highlights that an adaptive web-based training platform is an effective tool to promote CBME. EMC completion was associated with significant improvement in identifying clinically relevant diagnoses, providing a model for integrating CBME into subspecialized areas of training.