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Background and study aims: Capsule endoscopy may play a role in the evaluation of patients presenting with acute upper gastrointestinal hemorrhage in the emergency department. Patients and methods: We evaluated adults with acute upper gastrointestinal hemorrhage presenting to the emergency departments of two academic centers. Patients ingested a wireless video capsule, which was followed immediately by a nasogastric tube aspiration and later by esophagogastroduodenoscopy (EGD).We compared capsule endoscopy with nasogastric tube aspiration for determination of the presence of blood, and with EGD for discrimination of the source of bleeding, identification of peptic/inflammatory lesions, safety, and patient satisfaction. Results: The study enrolled 49 patients (32 men, 17 women; mean age 58.3 ± 19 years), but three patients did not complete the capsule endoscopy and five were intolerant of the nasogastric tube. Blood was detected in the upper gastrointestinal tract significantly more often by capsule endoscopy (15 /18 [83.3 %]) than by nasogastric tube aspiration (6 /18 [33.3 %]; P=0.035). There was no significant difference in the identification of peptic/ inflammatory lesions between capsule endoscopy (27 /40 [67.5 %]) and EGD (35 /40 [87.5 %]; P= 0.10, OR 0.39 95%CI 0.11-1.15). Capsule endoscopy reached the duodenum in 45/46 patients (98 %). One patient (2.2 %) had self-limited shortness of breath and one (2.2 %) had coughing on capsule ingestion. Conclusions: In an emergency department setting, capsule endoscopy appears feasible and safe in people presenting with acute upper gastrointestinal hemorrhage. Capsule endoscopy identifies gross blood in the upper gastrointestinal tract, including the duodenum, significantly more often than nasogastric tube aspiration and identifies inflammatory lesions, as well as EGD. Capsule endoscopy may facilitate patient triage and earlier endoscopy, but should not be considered a substitute for EGD. [ABSTRACT FROM AUTHOR]

Background and study aims: Colon capsule endoscopy (CCE) offers an alternative approach for endoscopic visualization of the colon. Some of the current CCE bowel cleansing regimens use sodium phosphate, which has raised safety concerns. Therefore, the aim of the current study was to test the feasibility and efficacy of a new low-volume, sodium phosphate-free polyethylene glycol (PEG) bowel preparation. Methods: The first 26 patients (original cleansing procedure) received a colon cleansing regimen of PEG plus ascorbic acid: patients drank 1L in the evening and 0.75 L in the morning before capsule ingestion. Patients also drank an additional 0.5 L PEG boost and an optional 0.25 L PEG boost during the capsule procedure. Following an interim analysis, the cleansing procedure of the subsequent 24 patients was modified, with the morning intake before capsule ingestion being increased to 1L, as well as the second boost (0.25 L) being administered 1-2 hours earlier (modified cleansing procedure). Results: The overall colon cleanliness was considered to be good or excellent in 83% (original cleansing procedure) and 82% (modified cleansing procedure) of patients, without any significant difference between regimens (P>0.05). In 37/49 (76 %) of the CCE procedures, the hemorrhoidal plexus was identified and thus the examination was considered complete, with no significant differences between the two CCE cleansing procedures. The capsule sensitivity and specificity for detecting colonic polyps ≥6mm were 91% (95 %CI 70%-98%) and 94% (95 %CI 87%-97%), respectively, compared with standard optical colonoscopy. Conclusion: A colon cleansing procedure using PEG +ascorbic acid for capsule colonoscopy yielded an adequate cleansing level in >80% of patients, a completion rate of 76%, and good accuracy for detecting polyps. This procedure may be considered as an alternative, particularly for patients in whom sodium phosphate-based preparations are contraindicated. [ABSTRACT FROM AUTHOR]

There were a number of interesting abstracts presented at the 2012 Digestive Disease Week (DDW; 19-22 May, San Diego, California, USA) that covered gastrointestinal bleeding and endoscopy. The following abstracts are those that were found to have particular high clinical importance and the potential for direct impact on the endoscopic care of patients. [ABSTRACT FROM AUTHOR]

The article presents a study that investigates the effectiveness of reducing gastrointestinal (GI) complications in coxibs in patients with osteoarthritis or rheumatoid arthritis. It describes the method of the study that observes patients treated with maximum dose of coxibs and non-steroidal anti-inflammatory drugs (NSAIDs). It notes the result of the study which indicates that reducing the gastrointestinal complications of coxibs did not offset its increased cost compared to NSAIDS.

Purpose: Recent evidence suggests that an empiric trial of omeprazole (the "omeprazole test") is sensitive and specific for diagnosing gastroesophageal reflux disease (GERD) as the cause of noncardiac chest pain. Our objective was to examine the clinical, economic, and policy implications of alternative diagnostic strategies for patients with noncardiac chest pain.Methods: Decision analysis was used to evaluate the clinical and economic outcomes of two diagnostic strategies that begin with the omeprazole test (60 mg daily for 7 days) followed sequentially by invasive testing utilizing endoscopy, ambulatory 24-hour esophageal pH monitoring, and esophageal manometry as necessary, compared with two traditional strategies involving sequential invasive diagnostic tests. Cost estimates were based on Medicare reimbursement and the Red Book of average wholesale drug prices. Probability estimates were derived from a systematic review of the medical literature.Results: The average cost per patient for the four diagnostic strategies varied from $1,859 to $2,313. Strategies utilizing the initial omeprazole test resulted in 84% of patients being symptom free at 1 year, compared with 73% to 74% for the strategies that began with invasive tests. The strategy of the omeprazole test, followed if necessary by ambulatory pH monitoring, then manometry, and then endoscopy, was both most effective and least expensive. It led to an 11% improvement in diagnostic accuracy and a 43% reduction in the use of invasive diagnostic tests, thus yielding an average cost savings of $454 per patient, compared with the strategy of beginning with endoscopy, then pH monitoring, and then manometry.Conclusions: Among patients with noncardiac chest pain, diagnostic strategies that begin with the omeprazole test result in reduced costs, improved diagnostic certainty, and a greater proportion of symptom-free patients at 1 year than do traditional strategies that begin with invasive diagnostic tests. [ABSTRACT FROM AUTHOR]

Background and Aims: We constructed the Toronto IBD Global Endoscopic Reporting [TIGER] score for inflammatory bowel disease [IBD]. The aim of our study was to develop and validate the TIGER score against faecal calprotectin [FC], C-reactive protein [CRP], and IBD Disk., Methods: A cross-sectional study was performed among 113 adult patients (60 Crohn's disease [CD] and 53 ulcerative colitis [UC]). In the development and usability phase, blinded IBD experts reviewed and graded ileocolonoscopy videos. In the validity phase the TIGER score was compared with: [1] the Simple endoscopic Score for CD [SES-CD] and the Mayo endoscopic score in CD and UC, respectively; [2] FC and CRP; and [3] IBD Disk., Results: Inter-observer reliability of the TIGER score per segment between reviewers was excellent: interclass correlation coefficient [ICC] = 0.94 [95% CI: 0.92-0.96]. For CD patients, overall agreement per segment between SES-CD and TIGER was 91% [95% CI: 84-95] with kappa coefficient 0.77 [95% CI: 0.63-0.91]. There was a significant correlation between TIGER and CRP [p <0.0083], and TIGER and FC [p <0.0001]. In addition, there was significant correlation between TIGER and IBD Disk [p <0.0001]. For UC patients, overall agreement per segment between Mayo endoscopic score and TIGER was 84% [95% CI: 74%-90%] and kappa coefficient 0.60 [95% CI: 0.42-0.808]. There was a significant correlation between TIGER and FC [p <0.0001]. There was a significant correlation between TIGER and IBD Disk [p <0.0001]., Conclusions: The TIGER score is a reliable and simple novel endoscopic score that can be used for both CD and UC patients and captures full endoscopic disease burden., (© The Author(s) 2021. Published by Oxford University Press on behalf of European Crohn’s and Colitis Organisation. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background and Study Aim: Esophageal capsule endoscopy (ECE) provides an alternative, minimally invasive modality for evaluating the esophagus. This study evaluates the performance and test characteristics of a second-generation esophageal capsule endoscope, the PillCam ESO 2., Methods: Adults with known or suspected esophageal disease were included. Using the simplified ingestion procedure, each patient underwent capsule endoscopy with the PillCam ESO 2. Following ECE, esophagogastroduodenoscopy (EGD) was performed on the same day by an investigator who was blinded to the results of the ECE. In random order, capsule endoscopy videos were read and interpreted by the study investigator blinded to EGD results., Results: 28 patients (19 men, 9 women; mean age 53.3 years) were included. In 82 % of the patients, at least 75 % of the Z line was visualized by the PillCam ESO 2. A per-lesion analysis demonstrated that the PillCam ESO 2 had definitive results in 30/43 lesions (69.8 %) and EGD in 29/43 (67.4 %), P value = 0.41. Compared with EGD for detecting suspected Barrett's esophagus and esophagitis, the PillCam ESO 2 had a sensitivity of 100 % and a specificity of 74 %, and a sensitivity of 80 % and a specificity of 87 %, respectively. The PillCam ESO 2 demonstrated 86 % agreement with EGD in describing the Z line (kappa statistic 0.68). The modified ingestion protocol provided excellent cleansing, with bubbles/saliva having no or only a minor effect on Z line images in 86 % of cases., Conclusions: The PillCam ESO 2 demonstrated excellent visualization of the Z line. Compared with standard EGD, the PillCam ESO 2 had good test characteristics with high rates of detection of suspected Barrett's esophagus and esophagitis. This study provides indirect validation of the simplified ingestion procedure. The PillCam ESO 2 acquires high quality esophageal images, performs safely, and should be able to replace the current PillCam ESO.

Health-related quality of life is a multidimensional construct and patient-centered outcome that patients value highly. In individuals with untreated GERD, multiple studies have demonstrated significant impairment in HRQOL. Treatment restores HRQOL to "normal" population levels. In this era of limited health care resources, formulary restrictions, and disease management guidelines, a more standardized approach to GERD diagnosis and management, through the utilization of a GERD-specific symptom rating scale and HRQOL measure(s), may be just what the doctor ordered.

Objectives: Assessment of health-related quality of life (HRQOL) outcomes in studies of liver disease and liver transplantation is necessary. Reliable and valid disease-targeted HRQOL measures are thus needed. The objective of this study was to develop a reliable and valid self-report HRQOL instrument for ambulatory adults with chronic liver disease., Methods: The Liver Disease Quality of Life instrument, LDQOL 1.0 (an HRQOL measure that uses the SF-36 as a generic core and 12 disease-targeted multi-item scales) was administered in a multicenter, cross-sectional field test to 221 ambulatory adults with advanced, chronic liver disease referred for primary liver transplantation evaluation. Disease-targeted scales included liver disease-related symptoms, liver disease-related effects on activities of daily living, concentration, memory, sexual functioning, sexual problems, sleep, loneliness, hopelessness, quality of social interaction, health distress, and self-perceived stigma of liver disease. We estimated the internal consistency reliability (Cronbach's alpha) for multi-item scales and construct validity., Results: Interial consistency reliability coefficients were excellent, ranging from 0.62 to 0.95, with 19 of 20 scales >0.70. Multitrait scaling analysis provided strong support for item discrimination across scales, and exploratory factor analysis demonstrated distinguishable physical, mental, and social health dimensions. Significant associations were found between worse HRQOL and worse Child-Pugh class, worse self-rated liver disease severity, and increased number of disability days., Conclusions: The results of this multicenter field test provide support for the reliability and validity of the LDQOL 1.0 as an HRQOL outcome measure for individuals with chronic liver disease.

Background & Aims: Few data are available to evaluate health-related quality of life (HRQOL) of people with irritable bowel syndrome (IBS). We evaluated and compared the impact of IBS on HRQOL using previously reported HRQOL data for the U.S. general population and for people with selected chronic diseases., Methods: Using the SF-36 Health Survey, we compared the HRQOL of IBS patients (n = 877) with previously reported SF-36 data for the general U.S. population and for patients with gastroesophageal reflux disease (GERD), diabetes mellitus, depression, and dialysis-dependent end-stage renal disease (ESRD)., Results: On all 8 SF-36 scales, IBS patients had significantly worse HRQOL than the U.S. general population (P < 0. 001). Compared with GERD patients, IBS patients scored significantly lower on all SF-36 scales (P < 0.001) except physical functioning. Similarly, IBS patients had significantly worse HRQOL on selected SF-36 scales than patients with diabetes mellitus and ESRD. IBS patients had significantly better mental health SF-36 scale scores than patients with depression (P < 0.001)., Conclusions: IBS patients experience significant impairment in HRQOL. Decrements in HRQOL are most pronounced in energy/fatigue, role limitations caused by physical health problems, bodily pain, and general health perceptions. These data offer further insight into the impact of IBS on patient functional status and well-being.

Objective: To evaluate the diagnostic accuracy of a trial of a high-dose proton pump inhibitor (the omeprazole test) in detecting gastroesophageal reflux disease (GERD) in patients with heartburn symptoms., Design: A randomized, double-blind, placebo-controlled, crossover trial., Patients and Setting: Forty-three consecutive patients with symptoms suggestive of GERD were enrolled at a Veterans Affairs medical center., Main Outcome Measures: Symptom response to the omeprazole test vs placebo in GERD-positive and GERD-negative patients; sensitivity, specificity, and positive and negative predictive values of the omeprazole test; and cost per correct diagnosis achieved with the omeprazole test compared with traditional diagnostic strategies., Results: Of 42 patients (98%) who completed the study, 35 (83%) were classified as GERD positive and 7 (17%) as GERD negative. Twenty-eight GERD-positive and 3 GERD-negative patients responded to the omeprazole test, providing a sensitivity of 80.0% (95% confidence interval, 66.7%-93.3%) and a specificity of 57.1% (95% confidence interval, 20.5%-93.8%). Economic analysis revealed that the omeprazole test saves $348 per average patient evaluated, and results in a 64% reduction in the number of upper endoscopies performed and a 53% reduction in the use of pH testing., Conclusions: The omeprazole test is sensitive and fairly specific for diagnosing GERD in patients with typical GERD symptoms. This strategy could result in significant cost savings and decreased use of invasive diagnostic tests.

Over the past twenty years, outcomes research has emerged as a methodology to systematically evaluate medical practice and outcomes of care. The assessment of outcomes in clinical practice can improve the quality of care delivered to patients. More specifically, improved quality can be realized by identifying endoscopic practices that are cost-efficient, by reducing the variability of endoscopic interventions, and by eliminating those endoscopic interventions that appear to be ineffective. The aims of this article are to provide practical information to the practicing endoscopist on which outcomes are important to measure in patients with gastrointestinal hemorrhage, and to detail methods of how to accomplish this.

Background: Orthotopic liver transplantation in the United States is primarily limited by a shortage of donor organs., Methods: To better understand the low rates of organ donation in the United States and identify areas for potential improvement, we analyzed detailed demographic and mortality-specific data from 10,689 adult cadaveric liver donors obtained from the United Network for Organ Sharing from April 1, 1994 to March 31, 1997. Comparative U.S. population demographic and economic data were obtained from the U.S. census., Results: As compared with the U.S. population, we found there to be significantly fewer nonwhite (P=0.001) and foreign-born donors (P=0.001); 58.9% of liver donors were male (P=0.001). The mean age was 40.6 years; yet during the 3-year period analyzed, there was a significant trend toward increasing age of donors. Median household income was 18% to 32% lower in the donor population than in the general U.S. population. In 91.2% of cases, the donor cause of death was listed as cerebrovascular stroke or head trauma. Numerous significant interracial differences were found in both the donor mechanism and circumstance of death. These included black donors being more likely to have gunshot wound as the listed mechanism of death (P=0.001) and to have homicide as the listed circumstance of death (P=0.001)., Conclusions: Nonwhites and foreign-born individuals are significantly underrepresented in the U.S. liver donor population. Furthermore, donors seem to be poorer than the general U.S. population. Increasing the liver donor pool, especially among minorities, will require creative and thoughtful public initiatives.

Esophageal variceal hemorrhage (EVH) is a serious and expensive sequela of chronic liver disease, leading to increased utilization of resources. Today, endoscopic sclerotherapy (ES) and endoscopic ligation (EL) are the accepted, community standards of endoscopic treatment of patients with EVH. However, there are no published studies comparing the economic costs of treating EVH using these interventions. As part of a prospective, randomized trial comparing ES and EL for the treatment of EVH, we estimated the direct costs of health care utilization and cost-effectiveness for the prevention of variceal rebleeding and patient survival at 1-year follow-up. Treatment groups were similar in incidence of variceal rebleeding (41.9% vs. 42.9%), variceal obliteration (41.9% vs. 40.0%), hospital days, blood transfusions, shunt requirements, and survival (71.0% vs. 60.0%). There were significantly more treatment failures for active bleeding using EL (42% vs. 0%; P =.027) and esophageal stricture formation in the ES-treated patients (19.4% vs. 2.9%; P = 0.03). Median total direct cost outcomes were similar between groups (EL = $9,696 and ES = $13,197; P =.46). EL and ES had similar cost/variceal rebleeding prevented ($28,678 vs. $29,093) and cost/survival ($27,313 vs. $23,804). In the subgroup of active bleeders, ES had a substantially lower cost/survival ($28,523 vs. $51,696). We conclude that resource utilization was similar between treatment groups and that the choice of endoscopic therapy for EVH must still rely on clinical grounds. Further studies comparing costs and resource utilization in this patient population are needed.

Objective: We report the clinical outcomes and direct medical costs of 155 patients with severe peptic ulcer hemorrhage and a nonbleeding visible vessel at emergency endoscopy treated with endoscopic hemostasis or medical-surgical therapy., Methods: In two consecutive, prospective, randomized, controlled trials, patients were randomly assigned to endoscopic hemostasis (heater probe, bipolar electrocoagulation, or injection sclerosis) or medical-surgical treatment. Study endpoints included the incidence of severe ulcer rebleeding and emergency surgery, length of hospital stay, blood transfusion requirements, mortality rate, and direct costs of utilized health care. Direct medical costs were estimated using combined fixed and variable institutional costs for consumed resources and Medicare reimbursement rates., Results: Compared with medical-surgical treatment, endoscopically treated patients had significantly lower rates of severe ulcer rebleeding (p = 0.004), emergency surgery (p = 0.002 and p = 0.019, 0.024), and blood transfusions (p = 0.025). Observed inter-trial differences in ulcer rebleeding rates may be partially explained in a multivariate model by covariates of comorbid disease and inpatient ulcer bleeding. In both trials, length of hospital stay, mortality rates, and treatment-related complications were similar. Estimated median direct costs per patient differed: The first trial had lower costs with endoscopic hemostasis ($4254, vs $4620 for electrocoagulation and $5909 for medical-surgical treatment), yet the second trial yielded lower costs with medical-surgical treatment ($3169, vs $3477 for injection sclerosis and $4098 for heater probe)., Conclusions: Compared with medical-surgical therapy, endoscopic hemostasis for severe ulcer hemorrhage and a nonbleeding visible vessel yielded significantly better patient outcomes and was safe. This procedure may or may not yield lower direct medical costs and cost savings.

Background & Aims: Evaluation of new patients with noncardiac chest pain (NCCP) may require a variety of costly tests. The aim of this study was to evaluate the efficacy of the omeprazole test (OT) in diagnosing gastroesophageal reflux (GERD) in patients with NCCP and estimate the potential cost savings of this strategy compared with conventional diagnostic evaluations., Methods: Thirty-nine patients referred by cardiologists were enrolled. Baseline symptoms were recorded, and the patients were randomized to either placebo or omeprazole (40 mg AM and 20 mg PM) groups for 7 days. Patients were crossed over to the other arm after a washout period and repeat baseline symptom assessment. All patients underwent 24-hour esophageal pH monitoring and upper endoscopy before randomization., Results: Thirty-seven patients (94.9%) completed the study. Twenty-three (62.2%) were classified as GERD positive and 14 as GERD negative. Eighteen (78%) GERD-positive patients and 2 (14%) GERD-negative patients had a positive OT (P < 0.01), yielding a sensitivity of 78.3% (95% confidence interval, 61.4-95.1) and specificity of 85.7% (95% confidence interval, 67.4-100). Economic analysis showed that the OT saves $573 per average patient evaluated and results in a 59% reduction in the number of diagnostic procedures., Conclusions: The OT is sensitive and specific for diagnosing GERD in patients with NCCP. This strategy results in significant cost savings and decreased use of diagnostic tests.

Irritable Bowel Syndrome (IBS) is a commonly diagnosed gastrointestinal condition which is seen by both primary care providers and gastroenterologists. In the United States, it has been estimated there are upwards of 3.5 million physician visits annually by patients with IBS with these patients representing a large percentage of subspecialty referrals. Interestingly, there are limited data on the rates of health care utilization by patients with IBS and even less data on the economic impact of IBS at a societal level. The objectives of this review of the extant literature are to report on IBS and health care utilization, define and review methods for economic costs assessments in IBS, and evaluate published studies which have examined the economic impact of IBS.