Effective Communication Strategies and Tools for Improving Treatment Outcomes in Patients With Chronic Idiopathic Constipation and Irritable Bowel Syndrome With Constipation
Patients with chronic idiopathic constipation and irritable bowel syndrome with constipation experience an array of gastrointestinal symptoms. Given the subjective nature of these disorders, patient self-reporting is critical to diagnosis and monitoring response to therapy. Unfortunately, many patients are reluctant to discuss bowel symptoms with their healthcare providers. Differences in sex, health literacy, and age can influence symptom reporting. Negative patient-physician relationships and dissatisfaction with care lead patients to seek alternative treatments, switch healthcare providers, or discontinue care. Thus, adopting a patient-centered communication style can help create a shared understanding of patients' symptoms, achieve accurate symptom reporting, expedite diagnosis, and facilitate appropriate treatment plans. Currently, there are multiple symptom and quality-of-life scales available to assist healthcare providers in this endeavor. These scales also allow for the monitoring of constipation-related symptoms and symptom severity. When using patient self-assessments to measure treatment responses, scale selection may depend on the number of symptoms being assessed, the duration and frequency of assessments, and patients' comprehension and language skills.
Real-World Treatment Strategies to Improve Outcomes in Patients With Chronic Idiopathic Constipation and Irritable Bowel Syndrome With Constipation
Chronic idiopathic constipation and irritable bowel syndrome with constipation are complex, overlapping conditions. Although multiple guidelines have informed healthcare providers on appropriate treatment options for patients with chronic idiopathic constipation and irritable bowel syndrome with constipation, little direction is offered on treatment selection. First-line treatment options usually include fiber and over-the-counter osmotic laxatives; however, these are insufficient for many individuals. When these options fail, prescription secretagogues (plecanatide, linaclotide, lubiprostone, and tenapanor [pending commercial availability]), or serotonergic agents (prucalopride and tegaserod) are generally preferred. Individuals experiencing concurrent abdominal pain and/or bloating may experience greater overall improvements from prescription therapies because these agents have been proven to reduce concurrent abdominal and bowel symptoms. Should initial prescription treatments fail, retrying past treatment options (if not adequately trialed initially), combining agents from alternative classes, or use of adjunctive therapies may be considered. Given the broad spectrum of available agents, therapy should be tailored by mutual decision-making between the patient and practitioner. Overall, patients need to be actively monitored and managed to maximize clinical outcomes.
An innovative prep-less x-ray imaging capsule for colon polyp detection [Meeting Abstract]
Introduction: Colorectal cancer is the third most common cancer for both men and women1. Despite the effectiveness of colon cancer screening only 44% of eligible patients get screened. Often related to not wanting an invasive procedure or not wanting to be sedated. Current non-invasive option include stool based tests, pillcam colon and CT colonography, both requiring a bowel cleanse. Recently there is a new x-ray capsule, which does not require a bowel cleanse prior to ingestion. The case below shows the correlation between x-ray capsule and optical colonoscopy for colon polyp detection. Case Description/Methods: A 55 year old male with no significant medical problems present for colon cancer screening. He has no family history of colon cancer or polyps. He denies any gastrointestinal complaints. Prior to undergoing colonoscopy, the patient ingests the x-ray capsule, using ultra-low dose x-ray imaging 3-dimensional (3D) images of the colon are created. This is accomplished without needing a bowel cleanse. Scans are taken during capsule motion in the colon and transmitted data to an external recorder unit attached to the patients' lower back. Using both data colon scans and the capsule position tracking a reconstructed 3D colon segments are generated. A 10 mm polyp was identified in the ascending colon. A subsequent colonoscopy was performed identifying the lesion, which was removed by snare polypectomy (Figure 1).
Discussion(s): Colon cancer screening has decreased the mortality of colon cancer. Colonoscopy is the gold standard, but some patients prefer non-invasive option. X-ray capsule is able to achieve 3D imaging using ultra low dose radiation. Future studies are needed to determine of this technology will play a role in colon cancer screening
Outstanding research award in the interventional endoscopy category (trainee) new automated cleaning system is more effective in reducing bioburden vs standard manual clean in duodenoscopes [Meeting Abstract]
Introduction: Multiple recent outbreaks of multidrug resistant organisms (MDRO) related to contaminated duodenoscopes have led to increased scrutiny of duodenoscope standard reprocessing methods. A key component of duodenoscope reprocessing is the cleaning step that occurs before high-level disinfection (HLD) or sterilization. Perfect adherence to manufacturer Instructions for Use (IFU) for manual cleaning can be difficult to achieve due to technical complexity and is open to human factor error. Adequate cleaning is measured against FDA and industry maximum allowed contaminants post cleaning of protein<6.4 ug/cm^2 and carbohydrates<2.2 ug/cm^2. Inadequate cleaning increases the risk for inadequate high-level disinfection and the possibility of procedures being performed with contaminated duodenoscopes. A new cleaning process has been developed to fully automate the cleaning step using turbulent flow technology.
Method(s): A total of 48 therapeutic ERCP procedures were performed utilizing Olympus TJF-Q180V duodenoscopes. After bedside point of use cleaning, 21 duodenoscopes were manually cleaned by trained technicians following the manufacturer IFU. 27 duodenoscopes were cleaned using the automated cleaning system. Duodenoscope instrument channels and distal elevator areas were sampled for residual protein and carbohydrates after cleaning.
Result(s): The automated cleaning process resulted in a lower average level of residual protein and carbohydrate compared to standard manual cleaning (Table 1). Using FDA and industry standards as a benchmark, the automated cleaning process reduced levels of protein and carbohydrate below safety threshold levels on all study duodenoscopes, while manual cleaning resulted in 4/21 (19%) duodenoscopes having protein or carbohydrate levels above FDA standards (p= 0.03).
Conclusion(s): Recent outbreaks of MDRO organisms transmitted after ERCP have brought to light the risk to patients when reusable duodenoscopes are not sufficiently reprocessed. The complex design of the device-involving multiple channels and an elevator mechanism at the distal tip-makes proper cleaning difficult. Without sufficient cleaning, subsequent HLD or sterilization can fail to adequately remove contaminants. As seen in this study, manual cleaning can be prone to error. With no incidents of elevated bioburden post cleaning, a fully automated cleaning technology appears to be a viable alternative for replacement of manual cleaning of duodenoscopes
Advances in Screening for Barrett Esophagus
Diagnosing Constipation Spectrum Disorders in a Primary Care Setting
Understanding pathophysiological causes of constipation is worthwhile in directing therapy and improving symptoms. This review aims to identify and fill gaps in the understanding of the pathophysiology of constipation, understand its prevalence, review diagnostic tools available to primary care physicians (PCPs), and highlight patients' expectations for the management of this common spectrum of disorders. Literature searches conducted via PubMed included terms related to constipation, diagnosis, and patient perceptions. Case studies were developed to highlight the differences between patients who may be appropriately managed in the primary care setting and those requiring specialty consultation. Myriad pathophysiological factors may contribute to constipation, including stool consistency, altered intestinal motility, gut microbiome, anorectal abnormalities, as well as behavioral and psychological factors. Common diagnoses of "primary constipation" include slow-transit constipation, defecation disorders, irritable bowel syndrome with constipation, and chronic idiopathic constipation. A detailed medical history should be conducted to exclude alarm features and PCPs should be familiar with pathophysiological factors that cause constipation, available diagnostic tools, alarm signs, and the various classification criteria for constipation subtypes in order to diagnose and treat patients accordingly. PCPs should understand when a referral to a gastroenterologist, anorectal specialist, pelvic floor physical therapist, and/or mental health specialist is appropriate.
Patient experience with NER1006 as a bowel preparation for colonoscopy: a prospective, multicenter US survey
BACKGROUND:, Salix Pharmaceuticals, Bridgewater, NJ) is a 1 L polyethylene glycol bowel preparation indicated for colonoscopy in adults. A US online survey assessed real-world ease of use and treatment satisfaction in individuals who received NER1006. METHODS:Adults were recruited from 444 US community gastrointestinal practices and provided a kit number for enrollment into an online survey to be completed within 2Â weeks. Survey questions evaluated colonoscopy history and prior bowel preparation(s) prescribed, patient experience during NER1006 administration, and patient satisfaction with the bowel preparation process. A 9-point predefined grading scale was used to evaluate ease of NER1006 preparation and consumption (range, 1 "very difficult" to 9 "very easy"); the perceived importance of volume requirement and clear liquid options (range, 1 "not important at all" to 9 "very important"); and patient satisfaction (range, 1 "not satisfied at all" to 9 "very satisfied"). RESULTS:1630 patients were enrolled, 1606 underwent colonoscopy, and 1598 completed the survey between September 15, 2018 and February 28, 2019. Among 1606 patients who had a colonoscopy, 62.5% were female, and the mean patient age was 54.4Â years (range 18-89Â years). Most patients (74.7%) did not report a family history of colon cancer, 62.6% had undergone prior colonoscopy, and 64.8% were undergoing colonoscopy for routine colorectal cancer screening. A majority (76.1%) of patients who completed the survey reported that NER1006 was very easy to prepare and take, and 89.9% were very or moderately satisfied with NER1006 overall. Most (97.6%) patients reported consuming all or most of the bowel preparation. Among 1005 patients with previous bowel preparation use, 84.7% indicated that their experience with NER1006 was much better or better (65.3%) or about the same (19.4%) compared with previously used bowel preparations, while only 15.3% rated NER1006 as worse or much worse. CONCLUSIONS:In this first real-world, US multicenter survey, patient-reported experience with NER1006 as a bowel preparation for colonoscopy was favorable and adherence was high. The majority of patients were very or moderately satisfied with the overall experience and found it much better/better than previously used bowel preparations. TRIAL REGISTRATION/BACKGROUND:Not applicable.
The Napoleon: A Pilot Feasibility Study of a Small Endoscopic Ruler for Accurate Polyp Measurement [Meeting Abstract]
INTRODUCTION: Multi-society recommendations state, "Given the importance of polyp size for informing surveillance intervals, documentation of a polyp > 10 mm within a report should be accompanied by an endoscopic photo of the polyp with comparison to an open snare or open biopsy forceps".1 We evaluate the feasibility of the Napoleon, an endoscopically-deployed small ruler to more accurately measure and document the size of colon polyps.
METHOD(S): The Micro-Tech Endoscopic Gauge (Non-FDA approved) named Napoleon, a catheter with a 15 mm ruler calibrated in 1 mm intervals with demarcations every 5 MM, was advanced through the biopsy channel of a colonoscope and positioned adjacent to a polyp to accurately measure polyp size (Image 1). Polyps sizes were first assessed visually and then measured using the Napoleon. Patients included were 50 to 85 years of age and undergoing screening or surveillance colonoscopy. Napoleon placement, extension/retraction, and photograph acquisition were evaluated on a 1-s10 scale (1 = Easy, 10 = Difficult).
RESULT(S): 23 patients were evaluated by 6 physicians. A total of 36 polyps were found. Each score represents the average of several polyps if more than one polyp was identified per patient (Table 1). The most polyps found in any patient was 3. Each polyp size was placed into 1 of 3 categories (Table 2): 1-5 mm (Diminutive), 6-9 mm (Small) and $ 10 mm (Large). 30 of the 36 total polyps (83%) were diminutive. 3 polyps were downgraded into the next smaller size category after measurement with the Napoleon - specifically, 1 polyp (33%) dropped from small to diminutive size and 2 polyps (67%) dropped from large to small size.
CONCLUSION(S): Prior studies on polyp size have shown that visual assessment is inaccurate.2 This study demonstrates the ease and feasibility of the Napoleon as an endoscopic measuring device. The majority of polyps found were diminutive (1-5 mm) and explains why there is such a minute difference noted in the weighted mean polyp size (0.28 mm). Of the 3 polyps that were visually assessed to be $ 10 mm, 2 of those polyps (67%) were measured to be < 10 mm, changing recommended surveillance from 3 years to 7-10 years.1 Further studies utilizing an endoscopic measuring tool such as the Napoleon are needed to evaluate the effect of accurate polyp measurement on our clinical management, training, and colonoscopy surveillance intervals
One Liter Polyethylene Glycol-Based NER1006 Is Efficacious as a Bowel Preparation for Colonoscopy in Patients with or Without Diabetes Mellitus: A Pooled Analysis of 2 Randomized, Phase 3 Studies [Meeting Abstract]
INTRODUCTION: Diabetes mellitus (DM) has been found to be an independent risk factor for inadequate bowel preparation for colonoscopy. NER1006, a 1 L polyethylene glycol (PEG)-based bowel preparation, was approved in the US in 2018 for colon cleansing in preparation for colono-scopy in adults. The aim of this study was to compare the efficacy of NER1006 bowel preparation in adults with DM compared with those without DM.
METHOD(S): A pooled post hoc analysis was conducted of two phase 3 studies (NOCT and MORA) of adults undergoing colonoscopy randomized to receive evening/morning split-dose regimen of NER1006, excluding those failing to meet entry criteria post-randomization and also not receiving NER1006. Overall colon cleansing success rates were assessed using the Boston Bowel Preparation Scale (BBPS; success defined as overall score >=6 with score >=2 in each segment [right, transverse, and left colon]) or Harefield Cleansing Scale (HCS; success defined as all 5 colonic segments scored 3 [clear liquid] or 4 [empty and clean] or >=1 segment scored 2 [brown liquid/fully removable semisolid stools] and other segments scored 3 or 4 [ie, good/excellent]). Good/excellent cleansing quality (colon segments free of stool; score 3 or 4) for each segment using the HCS and overall colon adenoma detection rate (ADR; number of patients with >=1 adenoma divided by total population) was also determined. P values were calculated using a 2-sided Fisher's exact test.
RESULT(S): 47 patients with type 1 DM or type 2 DM (reported as part of medical history) and 504 patients without DM were included. Some numeric differences in demographics in DM versus non-DM groups were observed (eg, male, 55.3% vs 45.4%; mean age, 63.6 y vs 56.4 y; weight, 89.7 kg vs 80.3 kg). There was no significant difference in the NER1006 overall colon cleansing success rate in patients with DM compared with those without DM using the BBPS (78.7% vs 87.3%; P = 0.12) or HCS (78.7% vs 89.5%; P = 0.05). Good/excellent cleansing quality in each colonic segment was achieved in a similar percentage of patients with DM or without DM (Figure 1). The overall ADR was significantly higher in patients with DM (51.1%) versus patients without DM (28.2%; P = 0.002), but ADR was comparable for the ascending colon (19.1% vs 12.3%; P = 0.18). Limitations include the small number of patients and lack of stratification by type of DM.
CONCLUSION(S): These data support that 1 L PEG-based NER1006 is efficacious as a bowel preparation in adults with DM undergoing colonoscopy
No dermatologist needed for this collagen filler: the rare presentation of collagenous gastritis in a patient with eosinophilic esophagitis [Meeting Abstract]
INTRODUCTION: Collagenous gastritis is a rare disease characterized by subepithelial collagen deposits within the gastric mucosa and chronic inflammation. While this disorder has similar histologic characteristics to the more common collagenous colitis, little is known about collagenous gastritis given its rarity. Fewer than 100 cases of collagenous gastritis have been reported to date, and our understanding of the disease is limited. The disease typically manifests with nonspecific symptoms including abdominal pain, diarrhea, and iron deficiency anemia (IDA). It is diagnosed histologically, and has been linked to various autoimmune disorders. We will describe a case of collagenous gastritis to further knowledge of this rare disease. CASE DESCRIPTION/METHODS: A 32-year-old man with a history of partial right lower lobectomy for carcinoid tumor 11 years prior, was referred for IDA, upper abdominal pain, and dysphagia. Initial endoscopy with biopsies revealed esophageal eosinophilia, consistent with eosinophilic esophagitis ( EoE). Gastroduodenal biopsies were unremarkable, and colonic biopsies revealed no collagenous or lymphocytic colitis. He was started on a PPI for 8-weeks and iron supplements, with improvement of symptoms. Following treatment, repeat EGD demonstrated resolution of his esophageal eosinophilia, and iron supplementation was discontinued. He re-presented 2 years later, with similar symptoms and recurrence of IDA. Repeat EGD demonstrated esophageal eosinophilia consistent with EoE. Endoscopy also revealed gastric erythema with nodularity (Figure 1), and subepithelial collagen deposition within the gastric body and fundus, consistent with collagenous gastritis (Fig 2a, 2b). He was restarted on iron supplement and a PPI, with improvement of symptoms. DISCUSSION: Collagenous gastritis has been associated with autoimmune disorders, and may be linked to EoE as described in this case. While diagnosis is histological, endoscopic features include gastric mucosal nodularity and erythema. Currently there is no clear consensus on the treatment of collagenous gastritis. Multiple therapies have been attempted including acid suppression, iron supplementation, hypoallergenic diets, among others, however to date there are no randomized control trials demonstrating treatment efficacy, and overall prognosis remains unclear. Awareness of this disorder is essential in its recognition. More information is needed to understand collagenous gastritis and determine how best to treat patients affected by this rare disease