Implementing visual cues to improve the efficacy of screening colonoscopy: exploiting the Hawthorne effect
Background/UNASSIGNED:Colonoscopy is the gold standard for colon cancer screening. Adenoma detection rate and a withdrawal time of 6 min are quality metrics to measure the efficacy of colonoscopy in colon cancer screening. The aim of our study was to exploit the Hawthorne effect in an effort to ensure adherence to a minimum 6-min withdrawal time and subsequently increase adenoma detection rate. Methods/UNASSIGNED:This was a retrospective single-center study where we reviewed the records of patients who underwent screening colonoscopy in 2015 and 2017. We divided our patient population into 2 groups. The first group of patients from 2015 underwent screening colonoscopy with no visual cues on the colonoscopy monitor. The second group of patients from 2017 had visual cues indicating withdrawal time on the colonoscopy monitor. Results/UNASSIGNED:Screening colonoscopy had a statistically significantly higher adenoma detection rate when performed with visual cues compared to without visual cues (25.3% vs. 19.45, P=0.04). Polyp detection rate was also higher in the group where visual cueing was used (52.9% vs. 22.9%, P<0.001). There were no statistically significant differences in actual withdrawal time or cecal intubation rates. Conclusions/UNASSIGNED:Visual cues indicating withdrawal time are a useful intervention that results in an increased adenoma detection rate. Given its practicality and cost effectiveness, we recommend universally implementing visual cues to ensure adherence to a minimum 6-min withdrawal time.
Esophageal Cancer: An Updated Surveillance Epidemiology and End Results Database Analysis
Background/UNASSIGNED:Esophageal cancer is the sixth leading cause of cancer-related deaths and the eighth most common cancer worldwide with a 5-year survival rate of less than 25%. Here we report the incidence, risk factors and treatment options that are available currently, and moving into the future. Methods/UNASSIGNED:We retrospectively analyzed the Surveillance Epidemiology and End Results (SEER) database made available by the National Cancer Institute in the USA. Specifically we extracted data from the years 2004 - 2015. Results/UNASSIGNED:In total we identified 23,804 patients with esophageal adenocarcinoma and 13,919 patients with esophageal squamous cell carcinoma. Males were at an increased risk of developing both types of esophageal cancer when compared to females. Most cases of adenocarcinoma were diagnosed as poorly differentiated grade III (42%), and most cases of squamous cell carcinoma were diagnosed as moderately differentiated grade II (39.5%). The most common stage of presentation for both adenocarcinoma (36.9%) and squamous cell (26.8%) carcinoma was stage IV. The worst outcomes for adenocarcinoma were noted with grade III tumors (hazard ratio (HR): 1.56, 95% confidence interval (CI): 1.44 - 1.68, P value: < 0.01), stage IV tumors (HR: 3.58, 95% CI: 3.33 - 3.85, P value: < 0.01) and those not treated with surgery (HR: 2.54, 95% CI: 2.44 - 2.65, P value: < 0.01). For squamous cell carcinoma, the worst outcomes were noted with grade III tumors (HR: 1.35, 95% CI: 1.23 - 1.49, P value: < 0.01), stage IV tumors (HR: 2.12, 95% CI: 1.94 - 2.32, P value: <0.01). Conclusions/UNASSIGNED:The incidence of esophageal adenocarcinoma in the USA is steadily on the rise. Conversely, the incidence of squamous cell carcinoma has been continually declining. While white males had an increased incidence of both types of esophageal cancer, a higher proportion of African Americans suffered from squamous cell carcinoma. Despite the wide spread use of proton pump inhibitors, adenocarcinoma continues to be a major public health concern.
Elevated International Normalized Ratio: A Risk Factor for Portal Vein Thrombosis in Cirrhotic Patients
Background/UNASSIGNED:Portal vein thrombosis (PVT) is a complication that is commonly seen in patients with cirrhosis and an entity that leads to increased mortality in patients who undergo liver transplantation. This study aims to establish a link between an elevated international normalized ratio (INR) and the presence of PVT in a cohort of cirrhotic patients. Methods/UNASSIGNED:We retrospectively reviewed the electronic medical records of all patients diagnosed with cirrhosis in SBH Health System from 2013 to 2018. Among these patients we extracted baseline demographic data, laboratory results, co-morbidities and the presence of PVT. Results/UNASSIGNED:In total there were 268 patients who met our inclusion criteria. Twenty-two patients had PVT, while 246 patients did not. Of the 22 patients with PVT there was a statistically significant increase in INR when compared to patients without PVT. There was also a statistically significant increase in total bilirubin, alkaline phosphatase and platelet count. Conclusions/UNASSIGNED:Elevated INR levels are associated with the presence of PVT in patients with cirrhosis. These findings suggest a hypercoagulable state and could assist clinicians in risk-stratifying patients when making the decision to initiate anti-coagulation therapy.
Achalasia Cardia Resulting in Bronchial Obstruction - A Case Series and Literature Review [Case Report]
Achalasia is a motility disorder of the esophagus that is characterized by loss of ganglionic neurons within the myenteric plexus of the lower esophageal sphincter (LES) resulting in failure of the LES to relax. Clinically this disorder presents with simultaneous dysphagia to solids and liquids, and if left untreated, leads to esophageal dilation, which can give rise to many adverse consequences. Extrinsic compression of respiratory structures is one such consequence, and rarely, cases of tracheal compression secondary to achalasia have been reported. However, cases of extrinsic bronchial compression are yet rarer. Here, we present a case series comprised of two patients with achalasia who presented with extrinsic bronchial compression by a dilated esophagus secondary to achalasia.
Rectal Dieulafoy's Lesion: A Rare Etiology of Lower Gastrointestinal Hemorrhage [Case Report]
A Dieulafoy's lesion is defined as a dilated submucosal vessel that erodes the overlying epithelium without evidence of a primary ulcer or erosion. It is a rare cause of gastrointestinal bleeding that is difficult to identify and subsequently manage. Most commonly, they occur in the upper gastrointestinal tract, namely the stomach. A Dieulafoy's lesion of the rectum, however, is an exceedingly rare presentation that can lead to life-threatening gastrointestinal bleeding. Our case consists of an 84-year-old man, who presented with lower gastrointestinal bleeding secondary to a Dieulafoy's lesion of the rectum.
Burkitt's Lymphoma of the Gastrohepatic Omentum: A Malignant Presentation of Pseudoachalasia [Case Report]
Achalasia is an intrinsic disorder of the esophagus that results from loss of ganglion cells in the lower esophageal sphincter. Clinically it is manifested by dysphagia to solids and liquids, weight loss, regurgitation, and chest pain. Pseudoachalasia, in contrast, is a rare entity that causes identical symptoms, but has a divergent underlying pathogenesis. The symptomology in these cases oftentimes occurs secondary to extrinsic compression of the esophagus, mostly attributable to malignancy. Although many cases of extrinsic esophageal compression have been reported in the literature, rarely has this occurred secondary to Burkitt's lymphoma in an adult. Here, we present a case of Burkitt's lymphoma resulting in pseudoachalasia in a 70-year-old female. The concurrence of these two entities in one patient makes this case presentation especially rare.
Rectal leiomyoma, a rare entity
Rectal tumors are often encountered as an incidental finding on screening colonoscopy. As per the World Health Organization, they are categorized according to their histologic appearance. These include epithelial tumors, mesenchymal tumors and lymphomas. Of interest, in our case, are mesenchymal tumors. These are sub-classified into leiomyomas and gastrointestinal stromal tumors. Our case is a 33-year old male who was diagnosed with a rectal leiomyoma. The uncommon incidence and subsequent management of a rectal leiomyoma in a male, make this case worthy for literature review.
Pepto-Bismol Tablets Resembling Foreign Bodies on Abdominal Imaging [Case Report]
A 28-year-old female presented to the emergency department (ED) with aÂ one-day history of severe, diffuse abdominal pain of sudden onset. In the ED, an abdominal x-ray was done, which showed two hyperdense disc-shaped structures. When her abdominal pain did not subside, the ED performed a computerized tomography (CT) scan of the abdomen and pelvis with contrast, which showed the two previously noted 16 mm disc-shaped objects to actually be located within the cecum. Based on the history and imaging, it was deduced that the two discs were likely to be Pepto-Bismol tablets (Proctor & Gamble Co., Cincinnati, OH). Most medications are radiolucent, but there are some that are radiopaque, including Pepto-Bismol (also known as bismuth subsalicylate). While quite a rare occurrence, it is important to know about since it can lead to unnecessary endoscopy and patient anxiety.
A Rare Case of Adult Colonic Intussusception from Benign Etiology [Case Report]
Defined as the tunneling of one bowel segment into an adjacent bowel segment, intussusception is typically observed in pediatric populations. Here, we present the case of a 78-year-old man who, in a series of unlikely events, developed colonic intussusception due to a benign lead point pathology. Intussusception of the colon is an uncommon occurrence in adults. However, adult colonic intussusception, observed in the absence of a malignant lead point pathology, represents a true clinical anomaly.
Idiopathic Isolated Colonic Varices: An Extremely Rare Condition [Case Report]
Colonic varices are an incredibly rare phenomenon to begin with; however, they are even more unusual when isolated and occurring in the absence of common comorbidities, like portal hypertension or portal vein thrombosis. We present a case of a 71-year-old female, who was asymptomatic and referred to gastroenterology for a routine colorectal cancer screening. The patient was ultimately found to have this anomalous condition when colonic varices were first identified on colonoscopy. Since these varices did not result from any obvious etiology, they were determined to be idiopathic colonic varices, an especially unusual presentation.