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Background and Aims: Adequate bowel preparation is crucial for a quality colonoscopy. Poor bowel preparation can result in longer procedural times, missed adenomas, earlier repeat procedures, increase costs, and decreased patient satisfaction. Pure-Vu (MOTUS GI, Tirat Carmel, Israel) is a system that facilitates intraprocedural cleaning of a poorly prepared colon during a colonoscopy by irrigating the colon and evacuating the fluid and feces. The study aims were to evaluate Pure-Vu's cleansing capabilities and its usability and safety in a live animal colon., Methods: The Pure-Vu system was used by 4 experienced gastroenterologists in 35 Yorkshire cross swine (66% female) that received a reduced bowel preparation to ensure an inadequate bowel preparation at baseline. Before colonoscopy the Pure-Vu was attached to the colonoscope, and the baseline prep was assessed during insertion. The Pure-Vu system was then used to cleanse the colon and the prep then assessed after Pure-Vu use., Results: No adverse effects and no failed or prematurely terminated cases were noted. Fourteen percent of the swine colons were adequately prepped at baseline (median Boston Bowel Preparation Scale [BBPS] score = 0 [25th percentile = 0; 75th percentile = 1; interquartile range = 1]) and improved to 100% after use of Pure-Vu (Wilcoxon signed rank test P < .001) (median BBPS score = 3 [25th percentile = 3; 75th percentile = 3; interquartile range = 0]). The physicians found Pure-Vu easy and intuitive to operate., Conclusions: The Pure-Vu system effectively cleaned inadequately prepped swine colons and proved to be easy to use. The Pure-Vu device, applied in clinical practice, may result in improved overall prep quality and a reduction in repeat examinations because of inadequately prepped colons., (Copyright © 2018 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Wide-area transepithelial sampling (WATS) with computer-assisted 3-dimensional analysis is a sampling technique that combines abrasive brushing of the Barrett's esophagus (BE) mucosa followed by neural network analysis to highlight abnormal-appearing cells., Methods: We performed a randomized trial of referred BE patients undergoing surveillance at 16 medical centers. Subjects received either biopsy sampling followed by WATS or WATS followed by biopsy sampling. The primary outcome was rate of detection of high-grade dysplasia/esophageal adenocarcinoma (HGD/EAC) using WATS in conjunction with biopsy sampling compared with biopsy sampling alone using standard histopathologic criteria. Secondary aims included evaluating neoplasia detection rates based on the procedure order (WATS vs biopsy sampling first), of each procedure separately, and the additional time required for WATS., Results: One hundred sixty patients (mean age, 63.4 years; 76% men; 95% white) completed the trial. The median circumferential and maximal BE extents were 1.0 cm (interquartile range: .0-5.0) and 4.0 cm (interquartile range, 2.0-8.0), respectively. The diagnostic yield for biopsy sampling alone was as follows: HGD/EAC, 7 (4.4%); low-grade dysplasia (LGD), 28 (17.5%); nondysplastic BE (NDBE), 106 (66.25%); and no BE, 19 (11.9%). The addition of WATS to biopsy sampling yielded an additional 23 cases of HGD/EAC (absolute increase, 14.4%; 95% confidence interval, 7.5%-21.2%). Among these 23 patients, 11 were classified by biopsy sampling as NDBE and 12 as LGD/indefinite for dysplasia (IND); 14 received biopsy sampling first and 9 WATS first (not significant) and most (n = 21; 91.7%) had a prior dysplasia history. WATS added an average of 4.5 minutes to the procedure., Conclusion: Results of this multicenter, prospective, randomized trial demonstrate that the use of WATS in a referral BE population increases the detection of HGD/EAC. (Clinical trial registration number: NCT03008980.)., (Copyright © 2018. Published by Elsevier Inc.)

Background: The literature to date has suggested a potential increase in colorectal cancer (CRC) among patients with breast cancer., Methods: We performed a systematic review of the literature and included 37 retrospective cohort studies and 8 case-control studies. The primary aim was to determine the prevalence of CRC. Secondary aims included analysis of adenomatous polyps and analysis of CRC prevalence by age. We calculated pooled prevalence rates and odds ratios (ORs) using random effects models with 95% confidence intervals (CI)., Results: We identified 1,055,917 individuals with breast cancer among whom 9097 cases of CRC were detected. The pooled event rate for CRC was 0.7% (95% CI, 0.6%-0.9%; I 2 =97%). Four case-control studies reported prevalence of CRC (N=17,873 patients with breast cancer and 70,366 controls), including 46 cases of CRC in the patients with breast cancer, and 272 CRC in the controls (OR, 1.2; 95% CI, 0.4%-3.7%; P = .7). Six studies reported prevalence of advanced adenomas in patients with breast cancer (N=1087) compared with controls (N=1356) with 62 cases of advanced adenomas in patients compared with 47 in the controls (OR, 1.5; 95% CI, 0.97-2.2; P = .07). In patients with breast cancer <50 years old (4 studies, N=64,706), the pooled OR was increased (OR, 2.5; 95% CI, 1.7-3.5; P =.001). In 3 studies of women <45 years old (N=92,594), the risk was increased (OR, 2.3; 95% CI, 1.7-2.6; P < .001)., Conclusions: Patients with breast cancer should not undergo CRC screening at intervals different from the general population. In patients with breast cancer <50 years old, CRC screening should be considered at age 45 years., (Copyright © 2017. Published by Elsevier Inc.)

Background and Aims: Video capsule endoscopy (VCE) has become a major diagnostic tool for small-bowel evaluation. However, retention of the video capsule endoscope remains a major concern., Methods: We performed a systematic review of VCE retention rates by using Pubmed and SCOPUS (1995-2015). We included studies that enrolled at least 10 patients, included VCE retention rates, and separated retention rates by indication. We used Comprehensive Meta-Analysis (Version 3.0) to calculate pooled prevalence rates with 95% confidence intervals (CIs) and assessed heterogeneity by using the Cochran Q statistic., Results: We included 25 studies (N = 5876) for patients undergoing VCE for evaluation of potential small-bowel bleeding, 9 studies (N = 968) for patients with suspected inflammatory bowel disease (IBD), 11 studies (N = 558) for patients with established IBD, and 8 studies for patients (N = 111) undergoing VCE for evaluation of abdominal pain and/or diarrhea. We used a random effects model and found that the pooled retention rate was 2.1% for patients with suspected small-bowel bleeding (95% CI, 1.5%-2.8%). Retention rates were 3.6% (95% CI, 1.7%-8.6%) for suspected IBD, 8.2% (95% CI, 6.0%-11.0%) for established IBD, and 2.2% (95% CI, 0.9%-5.0%) for abdominal pain and/or diarrhea. Based on subgroup analysis, subsequent VCE completion rates after performance of a patency capsule or CT enterography in patients with IBD to exclude retentions due to strictures was 2.7% (95% CI, 1.1%-6.4%). Reasons for retention were provided in 60 (77%) studies. The most common reasons for retention were small-bowel strictures, although etiology was not provided in all studies., Conclusion: VCE retention occurs in approximately 2% of patients undergoing evaluation for small-bowel bleeding and is most likely due to small-bowel strictures. Retention rates in patients with suspected or known IBD were approximately 4% and 8%, based on our meta-analysis. These rates decreased by half in those studies that used either a patency capsule or CT enterography to assess patency before performing VCE., (Published by Elsevier Inc.)

Background and Aims: GI angiodysplastic (GIAD) lesions are an important cause of blood loss throughout the GI tract, particularly in elderly persons. The aim of this study was to determine whether mortality rates in patients with GIAD were higher for weekend compared with weekday hospital admissions., Methods: We performed a retrospective study using the National Inpatient Sample database from 2000 to 2011 including inpatients with an International Classification of Diseases, Ninth Revision, Clinical Modification code for gastrointestinal GIAD (code 537.82 or 537.83). We assessed rates of delayed endoscopy (examinations performed >24 hours after admission), intensive care unit (ICU) admissions, and in-hospital mortality rates. Bivariate and multivariate logistic regression analyses were performed to identify risk factors for mortality., Results: There were 85,971 discharges for GIAD between 2000 and 2011, of which 69,984 (81%) were weekday hospital admissions and 15,987 (19%) were weekend admissions. Patients with weekend versus weekday admissions were more likely to undergo delayed endoscopic examination (35% vs 26%, P ≤ .0001). Mortality rates were higher for patients with weekend admissions (2% vs 1%, P = .0002). The adjusted odds ratio (aOR) for inpatient mortality associated with weekend admissions was elevated (2.4; 95% confidence interval [CI], 1.5-3.9; P = .0005). Rates of delayed endoscopic examinations were lower in patients with higher socioeconomic status (aOR = 0.77; 95% CI, 0.68-0.88). ICU admission rates were higher for weekend compared with weekday admissions (8% vs 6%, P = .004). The presence of a delayed endoscopic examination was associated with an increased length of stay of 1.3 days (95% CI, 1.2-1.4 days)., Conclusions: Weekend admissions for angiodysplasia were associated with higher odds of mortality, ICU admissions, higher rates of delayed endoscopic procedures, longer lengths of stay, and higher hospital charges., (Copyright © 2016 American Society for Gastrointestinal Endoscopy. All rights reserved.)

Background: Patients with left ventricular assist devices (LVADs) are at increased risk of GI bleeding (GIB), primarily from GI angiodysplastic lesions (GIAD)., Objective: To perform meta-analysis of the medical literature in order to determine prevalence and risk factors for GIB., Design: A literature search was performed to identify studies reporting GIB in LVAD patients. We extracted rates of prevalence, rebleeding, and overall mortality from each study. Pooled event rates and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated., Setting: Meta-analysis of 17 case-control and cohort studies., Patients: A total of 1839 LVAD patients of whom 1697 (92%) had continuous-flow LVADs., Results: The pooled prevalence of GIB in LVAD patients was 23% (95% CI, 20.5%-27%). Subgroup analysis demonstrated that older age (standard difference in means (SDm), 0.69; 95% CI, 0.23-1.15), and elevated creatinine (SDm, 0.65; 95% CI, 0.12-1.18, P = .02) were associated with GIB. Risk factors not associated with GIB included LVAD as destination therapy (OR 1.85; 95% CI, 0.8-4.3), prior history of GIB (OR 2.22; 95% CI, 0.83-5.96), hypertension (OR 1.6; 95% CI, 0.87-2.97), and/or the presence of a continuous-flow LVAD (OR 4.5; 95% CI, 2.1-9.5). Recurrence of GIB occurred in 9.3% (95% CI, 7%-12%), with a GIB mortality rate of 23% (95% CI, 16%-32%). The pooled event rates were 48% (95% CI, 39%-57%) for upper GIB, 22% (95% CI, 16%-31%) for lower GIB, and 15% (95% CI, 8%-25%) for small-bowel bleeding. GIAD in the proximal GI tract were the most common cause of GIB (29%)., Limitations: Lack of information regarding endoscopic therapy and follow-up in most studies., Conclusions: The prevalence of GIB is increased in patients with continuous-flow LVADs, primarily secondary to the presence of GIAD., (Copyright © 2014 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Video capsule endoscopy (VCE) is most commonly performed in the outpatient setting to evaluate obscure GI bleeding., Objective: To determine the impact of gender and inpatient status on VCE findings., Design: Retrospective study., Setting: Two tertiary medical centers and a VA medical center., Patients: A total of 167 inpatients and 540 outpatients undergoing 707 VCE examinations for obscure GI bleeding., Interventions: VCE study., Main Outcome Measurements: Patient age, sex, indication for VCE, gastric and small-bowel transit times, significant VCE findings including detection of blood in the lumen and major lesions outside the small bowel, and presence of comorbid conditions., Results: Significant VCE findings were identified more frequently during inpatient VCE examinations (48% vs 37%, P = .009). Endoscopic placement, nongastric passage, and incomplete studies to the cecum were more common for inpatient VCE examinations. Gastric transit time, but not small-bowel transit time, was longer in inpatient VCE studies. Inpatient VCE examinations were more common in male patients (73% vs 61%, P = .004) and patients with overt bleeding (83% vs 46%, P < .05). The overall diagnostic VCE rate was higher for male patients because of a higher prevalence of angiodysplastic lesions and major findings outside the small bowel., Limitations: Retrospective study. Lack of information regarding timing of VCE study, most recent episode of obscure bleeding, and comorbidity data for outpatients., Conclusion: The overall diagnostic yield was higher for inpatient VCE examinations. Male patients were more likely to demonstrate significant findings on both inpatient and outpatient VCE studies because of a higher prevalence of angiodysplastic lesions and findings outside the small bowel., (Copyright © 2011. Published by Mosby, Inc.)

Background: Chronic anticoagulation has been demonstrated to be a risk factor for GI bleeding (GIB) in patients undergoing endoscopic procedures., Objective: The aim of this study was to determine the incidence of GIB prospectively in a large cohort of patients enrolled in the Clinical Outcomes Research Initiative (CORI) database., Design: Anticoagulated patients undergoing endoscopic procedures were interviewed by phone 30 to 45 days after the procedure to determine potential adverse events and management of warfarin therapy in the periendoscopic period., Setting: Participating CORI sites, Stanford University Hospital, Veterans Administration Palo Alto Health Care System., Main Outcome Measurement: Postprocedural hemorrhagic or thrombotic events., Results: Thirteen CORI sites agreed to participate, including 120,886 procedures in 95,807 patients. We contacted 929 patients on warfarin therapy and enrolled 483 patients (52%). The majority of the patients were men with atrial fibrillation undergoing colonoscopy. Warfarin was temporarily suspended in 437 (90%) of the patients before the procedure, and 114 (22%) received periprocedural heparin therapy. There were 10 major hemorrhagic events (2%), and the rate of hemorrhage was not higher in the patients receiving periprocedural heparin therapy (P = .1). However, polypectomy was a risk factor for postprocedural hemorrhage (P = .02). One fatal stroke (0.2%) occurred in a patient 2 weeks after endoscopy; however, information regarding warfarin management was not available., Limitations: Small number of enrolled patients and lack of control group. Lack of information regarding prothrombin time before procedure, concurrent antiplatelet agents, and timing of bleeding in 50% of the cases. The study was underpowered to definitively conclude benefits of current guidelines regarding thrombosis or bleeding., Conclusions: Postprocedural hemorrhagic events were not increased in anticoagulated patients. Most patients receiving bridging therapy were managed according to current society guidelines., (Copyright 2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Barrett's esophagus (BE) has been detected in approximately 10% of patients with chronic GERD. Previous studies demonstrated a similar prevalence of BE in asymptomatic adults., Objective: To determine the prevalence of BE in asymptomatic women., Design: We invited women scheduled for routine screening colonoscopy (for colorectal cancer) and women undergoing endoscopic examination before bariatric surgery to participate. Patients experiencing heartburn symptoms more than once per month were excluded., Setting: Outpatients at Stanford University and Palo Alto VA Health Care System., Interventions: Biopsies of the esophagogastric junction in the setting of suspected BE, and completion of symptom and health-related quality of life questionnaires to ensure that subjects were asymptomatic., Main Outcome Measurement: Identification of BE., Results: We detected BE in 8 (6%) of 126 subjects, including 3 (5%) of 61 of the women in the colorectal cancer screening cohort and 5 (8%) of 65 of the women in the pre-bariatric surgery cohort, all of whom had BE measuring 2 cm or less (P = .30). Patients found to have BE were more likely to be older (mean age 60 years vs 49 years, respectively; P = .04), but there was no difference in mean body mass index, ethnicity, or tobacco or alcohol use between patients with and without BE. BE was only present in pre-bariatric surgery subjects younger than the age of 50 and was most common in the 61- to 70-year age cohort in both groups. Erosive esophagitis, microscopic reflux changes, and Helicobacter pylori infection were not more common in the pre-bariatric surgery group., Limitation: Small number of subjects with BE detected., Conclusions: Short-segment BE was detected in 6% of asymptomatic women undergoing screening endoscopic examinations.

Background: Barrett's esophagus (BE) results from metaplastic healing of injured esophageal mucosa after erosive esophagitis (EE)., Objective: Our purpose was to determine whether severity of esophagitis, indication for endoscopy, or proton pump inhibitor treatment affects the subsequent incidence of BE diagnosis in patients found to have EE on EGD performed for any indication., Design: We identified patients with primary or secondary International Classification of Diseases, 9th revision diagnosis codes of EE from 1996 to 2006 who had at least 2 EGDs on record. Patients with prevalent BE on the first EGD were excluded., Setting: Inpatients and outpatients at Stanford University and Palo Alto Veterans Affairs Health Care System., Interventions: Retrospective review of EGD and pathology reports to confirm BE., Main Outcome Measurements: Detection of BE after diagnosis of EE., Results: A total of 1095 patients were identified between 1996 and 2000, and 102 (9%) were included. Sixty-two (61%) patients were veterans, 87 (85%) were male, and 83 (81%) were white. The mean (+/-SD) age was 58 +/- 14 years (range 24-83 years). BE was detected in 9 (9%) patients (95% CI, 4.5%-17.6%) over a mean of 13.3 +/- 5.7 months (range 1-53.5 months), and all had prior grade 4 esophagitis. The mean BE length was 4 +/- 1.8 cm (range 1-18 cm). Six patients had upper GI bleeding as the indication for EGD, whereas the other 3 complained of dysphagia. The association of grade 4 esophagitis (P = .01) and GI hemorrhage (P = .01) to the subsequent detection of BE was highly statistically significant., Limitations: Retrospective study, small number of patients with BE after EE. All patients were receiving care at tertiary medical centers., Conclusions: BE was detected in 9% of patients with prior EE and was detected exclusively on follow-up of patients with severe esophagitis. The majority of the patients found to have BE had upper GI bleeding as the presentation for EGD.

Background: Previous studies that reported the incidence of perforation from a colonoscopy are limited by small sample sizes, restricted age groups, or single-center data., Objective: To determine the incidence and risk factors of colonic perforation from a colonoscopy in a large population cohort., Design: Retrospective, population-based, cohort study, followed by a nested case-control study., Setting: California Medicaid program claims database., Patients: A total of 277,434 patients (aged 18 years and older) who underwent a colonoscopy during 1995 to 2005, age, sex, and time matched to 4 unique general-population controls., Main Outcome Measurements: Perforation incidence in the 7 days after colonoscopy (or matched index date for controls) with odds ratio (OR); multivariate logistic regression to calculate adjusted ORs for subsequent analysis of risk factors., Results: A total of 228 perforations were diagnosed after 277,434 colonoscopies, which corresponded to a cumulative 7-day incidence of 0.082%. The OR of getting a perforation from a colonoscopy compared with matched controls (n = 1,072,723) who did not undergo a colonoscopy was 27.6 (95% CI, 19.04-39.92), P < .001. On multivariate analysis, when comparing the group that had a perforation after a colonoscopy (n = 216) with those who did not (n = 269,496), increasing age, significant comorbidity, obstruction as an indication for the colonoscopy, and performance of invasive interventions during colonoscopy were significant positive predictors. Performance of biopsy or polypectomy did not affect the perforation risk. The rate of perforation did not change significantly over time., Limitations: Validity of coding and capturing of all perforation diagnoses may possibly be deficient., Conclusion: The risk of perforation from a colonoscopy is low, but, despite increased experience with the procedure, it remains unchanged over time.

Background: Health-related quality of life is decreased in patients with GERD and Barrett's esophagus (BE)., Objective: To determine whether time-tradeoff (TTO) values would differ in patients with BE when patients were asked to trade away the potential risk of esophageal adenocarcinoma rather than chronic heartburn symptoms., Design: A prospective clinical trial., Patients: Subjects with biopsy-proven BE., Interventions: Custom-designed computer program to elicit health-state utility values, quality of life in reflux and dyspepsia (QOLRAD), and Medical Outcomes Survey short form-36 surveys., Main Outcome Measurements: TTO utility values for the annual cancer-risk-associated current health state and for hypothetical scenarios of dysplasia and esophageal cancer., Results: We studied 60 patients in the cancer-risk cohort (57 men, 92% veteran; mean age [standard deviation; SD], 65 years [11 years], mean GERD duration 17 years [12 years]). The heartburn cohort included 40 patients with GERD and BE with TTO values derived for GERD symptoms. The mean (SD) utility for nondysplastic BE was 0.91 (0.13) compared with 0.90 (0.12) for the heartburn cohort (P = .7). The mean utility values were significantly lower for scenarios of low-grade dysplasia (0.85 [0.12], P = .02) and high-grade dysplasia (0.77 [0.14], P < .005). The mean TTO was 0.67 (0.19) for the scenario of esophageal cancer. There was no correlation between the utility scores and the disease-specific survey scores., Limitations: TTO values were hypothetical for states of dysplasia and cancer., Conclusions: TTO utility values based on heartburn symptoms or annual risk of cancer in patients with nondysplastic BE are roughly equivalent. However, TTO utility values are significantly lower for health states with increasing cancer risks.