Faculty Bibliography

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

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

INTRODUCTION: Globally, prostate cancer is the most commonly diagnosed cancer in men. Radiation therapy remains a mainstay in the armamentarium in the treatment of this disease. Radiation proctopathy is a common side effect of this treatment modality with an incidence in patients treated with brachytherapy alone estimated to range from 8 to 13%, and up to 21% in combination with other modalities [2]. Radiation proctopathy typically presents with diarrhea, mucoid discharge, urgency, tenesmus, and bleeding. Argon plasma coagulation (APC) has become the primary therapeutic modality in the management of radiation injury. It is essential that physicians of all specialties (as well as others who care for these patients) be aware of the multiple complications of this therapy. More severe adverse events, notably rectal ulcers following APC therapy are not uncommon, with an incidence ranging from 3 to 16%. CASE DESCRIPTION/METHODS: A 67-year-old man with a history of prostate cancer treated with radiation therapy one year prior presented with intermittent rectal bleeding for one and a half months. A colonoscopy was performed, which revealed a small area near the dentate line characterized by slightly oozing neovascularized tissue consistent with radiation proctopathy. This area was treated with APC with good effect. Biopsies of this area revealed hyperplastic crypts, lamina propria fibrosis, and vascular ectasias compatible with radiation injury. Three months following treatment, the patient developed recurrent rectal bleeding. A flexible sigmoidoscopy revealed a deep nonbleeding ulcer in the rectum. Subsequent CT enterography and MRI of the pelvis demonstrated a deep rectal ulcer with abutment of a 1.5cm peri-prostatic abscess. The patient was followed closely over the next several months in concert with colorectal surgical colleagues, with serial imaging and subsequent resolution of the peri-prostatic abscess as well as cessation of rectal bleeding. DISCUSSION: As more patients with prostate cancer are treated with radiation therapy the incidence of radiation proctopathy is increasing. Although argon plasma coagulation has been shown to be an effective therapy for this issue, providers must consider and discuss with patients the potential complications of this otherwise effective and generally well-tolerated mode of treatment

BACKGROUND:Hepatitis B virus is a viral infection that can lead to acute and/or chronic liver disease, and hepatocellular carcinoma (HCC). Hepatitis B vaccination is 95% effective in preventing infection and the development of chronic liver disease and HCC due to hepatitis B. In 2011, the Centers for Disease Control updated their guidelines recommending that adults at high-risk for hepatitis B infection be vaccinated against hepatitis B including those with diabetes mellitus (DM). We hypothesize that adults at high-risk for hepatitis B infection are not being adequately screened and/or vaccinated for hepatitis B in a large urban healthcare system. AIM/OBJECTIVE:To investigate clinical factors associated with Hepatitis B screening and vaccination in patients at high-risk for Hepatitis B infection. METHODS:We conducted a retrospective review of 999 patients presenting at a large urban healthcare system from 2012-2017 at high-risk for hepatitis B infection. Patients were considered high-risk for hepatitis B infection based on hepatitis B practice recommendations from the Center for Disease Control. Medical history including hepatitis B serology, concomitant medical diagnoses, demographics, insurance status and social history were extracted from electronic health records. Multivariate logistic regression was used to identify clinical risk factors independently associated with hepatitis B screening and vaccination. RESULTS:< 0.05. CONCLUSION/CONCLUSIONS:Patients at high-risk for hepatitis B are not being adequately screened and/or vaccinated. Improvements in hepatitis B vaccination should be strongly encouraged by all healthcare systems.

Background and Aims: The Centers for Disease Control (CDC) recommends that baby boomers (adults born between 1945-1965) be screened for hepatitis C (HCV). Patients with HCV are at increased risk of co-infection with hepatitis B (HBV). We investigated HCV screening rates in a baby boomer cohort with chronic HBV or at high-risk for HBV infection from a large healthcare system. Methods: We conducted a retrospective cohort analysis of 792 baby boomers, evaluated at New York Langone (NYU) from 2012-2017 with chronic HBV or at high-risk for HBV infection. CDC guidelines were used to assess whether a patient was considered at high-risk for HBV infection. Medical history including hepatitis serology was extracted from electronic health records. Multiple logistic regression was used to identify clinical risk factors independently associated with HCV screening. Results: Among 792 patients, 419 (52.9%) were screened. Multivariate regression of factors significant (P<.05) on univariate analysis revealed that health insurance, end-stage renal disease (ESRD), chronic liver disease (CLD), diabetes mellitus (DM) and current alcohol use were each independently associated with HCV screening. The strongest predictors of HCV screening were ESRD (OR: 3.346; 95% CI: 1.688-6.634) and CLD (OR: 3.027; 95% CI: 2.102-4.359), while DM (OR: 0.680; 95% CI: 0.497-0.930) was associated with a decreased likelihood of prior screening. Conclusion: In a retrospective study of patients at NYU, the baby boomer cohort with chronic HBV or at high-risk for HBV infection are not being adequately screened for HCV. Improvement in HCV screening should be strongly encouraged by all healthcare systems.

Eosinophilic esophagitis (EoE) is an IgE-mediated allergic condition of the esophagus characterized by dense eosinophilic infiltrates. An association with atopic conditions suggests that EoE may be driven by both genetic and environmental factors, including food related exposures. Here, we present two cases of EoE in adult brothers with an update on the known genetic involvement in this disease. An 18-yearold male with allergic rhinitis and food allergies presented with abdominal pain, foul smelling BMs, and weight loss for 1 year. Upper endoscopy revealed linear furrows throughout the esophagus, biopsies of which demonstrated eosinophilia up to 150 per high-power field (HPF). Serum allergen testing indicated elevated IgE and multiple food sensitivities. His brother is a 36-year-old with a history of GERD and progressive dysphagia. He has no known allergies or atopic conditions. On EGD, the esophageal mucosa appeared normal, however biopsies also yielded eosinophilia up to 150/HPF. Serum allergen panel was negative with a mildly elevated IgE. Studies have supported a heritable component in EoE with recurrence risk ratios in first-degree relatives of patients ranging from 10-64. One retrospective study attributed 72% of heritability to a combined effect of genes and environment within nuclear families. Here we describe siblings who presented with symptomatic EoE within the same year. Both were diagnosed with a high burden of eosinophilia on endoscopic biopsies; however, their clinical presentation and findings differed. One patient had classic endoscopic findings of linear furrows with a history of atopic disease (food allergies and allergic rhinitis). While prior studies have not shown a statistically significant difference in signs and symptoms, endoscopic appearance, or atopic status between familial and sporadic EoE patients, our patients suggest there may be more variability within the familial EoE population than previously recognized. The histopathologic similarity between these two patients is consistent with reports of a conserved genomic "EoE transcriptome" in which eotaxin-3 (eosinophil-specific chemoattractant) was significantly over-expressed with levels correlating with end-organ eosinophilia. However, a longer latency period of disease in one brother points to possible differences in underlying susceptibility. Additional research is needed to refine our understanding of the complex interactions between genes and environment in this disorder. (Figure Presented)